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Front row seat: The role MMI assessors play in widening access to medical school
Medical Teacher
Abstract
Background:
While many medical schools utilize the Multiple Mini-Interview (MMI) to help select a diverse student body, we know little about MMI assessors' roles. Do MMI assessors carry unique insights on widening access (WA) to medical school? Herein we discuss the hidden expertise and insights that assessors contribute to the conversation around WA.
Methods:
Ten MMI assessors (1-10 years' experience) participated in semi-structured interviews exploring factors influencing equitable medical school recruitment. Given their thoughtfulness during initial interviews, we invited them for follow-up interviews to gain further insight into their perceived role in WA. Fourteen interviews were conducted and analyzed using a thematic analysis approach.
Results:
Assessors expressed concerns with diversity in medicine; dissatisfaction with the status quo fueled their contributions to the selection process. Assessors advocated for greater diversity among the assessor pool, citing benefits for all students, not only those from underrepresented groups. They noted that good intentions were not enough and that medical schools can do more to include underrepresented groups' perspectives in the admissions process.
Conclusion:
Our analysis reveals that MMI assessors are committed to WA and make thoughtful contributions to the selection process. A medical school selection process, inclusive of assessors' expertise is an important step in WA.
... Of these, 15 provided their ratings again the following year. In line with widening participation policies it is recommended to include raters that reflect patient diversity and promote inclusivity in medicine within raterbased selection tools [23], [24], [25] in order to reduce bias and enhance fairness by considering different perspectives and backgrounds in the evaluation process. Thus, to diversify the rater pool for the 2021 study, we recruited 11 additional community raters via online platforms for temporary job offers and e-mail lists of associations for people with a migration background. ...
Objectives: Situational Judgement Tests (SJT) are a cost-efficient method for the assessment of personal characteristics (e.g., empathy, professionalism, ethical thinking) in medical school admission. Recently, complex open-ended response format SJTs have become more feasible to conduct. However, research on their applicability to a German context is missing. This pilot study tests the acceptability, reliability, subgroup differences, and validity of an online SJT with open-ended response format developed in Canada (“Casper”).
Methods: German medical school applicants and students from Hamburg were invited to take Casper in 2020 and 2021. The test consisted of 12 video- and text-based scenarios, each followed by three open-ended questions. Participants subsequently evaluated their test experience in an online survey. Data on sociodemographic characteristics, other admission criteria (Abitur, TMS, HAM-Nat, HAM-SJT) and study success (OSCE) was available in a central research database (stav).
Results: The full sample consisted of 582 participants. Test-takers’ global perception of Casper was positive. Internal consistency was satisfactory in both years (α=0.73; 0.82) while interrater agreement was moderate (ICC(1,2)=0.54). Participants who were female (d=0.37) or did not have a migration background (d=0.40) received higher scores. Casper scores correlated with HAM-SJT (r=.18) but not with OSCE communication stations performance. The test was also related to Abitur grades (r=-.15), the TMS (r=.18), and HAM-Nat logical reasoning scores (r=.23).
Conclusion: This study provides positive evidence for the acceptability, internal consistency, and convergent validity of Casper. The selection and training of raters as well as the scenario content require further observation and adjustments to a German context to improve interrater reliability and predictive validity.
Objective
To explore the experiences and perceptions of rural and metropolitan applicants preparing for and completing all admission components for a provisional entry regional medical pathway.
Setting
Provisional entry regional medical pathway.
Participants
Provisional entry (school‐leaver) applicants ( N = 18) who completed a Multiple Mini‐Interview (MMI).
Design
Applicants were invited to participate in a semi‐structured interview regarding their experiences of the admissions process relative to their background (rural/metropolitan origin). A constructivist approach with a social accountability lens was taken for these semi‐structured interviews.
Results
Themes were related to whether the applicants were classified as rural or metropolitan origin and the impact of the applicant's geographical location and connections to the local community, differences in local school and social support, and challenges in allocating medical school preferences.
Conclusion
Overall, applicant perceptions and experiences of the admissions process were influenced both positively and negatively by whether they were of rural or metropolitan origin. Strategies are required to ensure applicants with genuine rural interest, whether they are of rural or metropolitan origin, have access to sufficient support and resources while applying to regional medical pathways to ensure they are not disadvantaged, thus meeting admissions goals of the program.
Introduction
Medicine remains an inequitable profession for women. Challenges are compounded for underrepresented women in medicine (UWiM), yet the complex features of underrepresentation and how they influence women’s career paths remain underexplored. This qualitative study examined the experiences of trainees self-identifying as UWiM, including how navigating underrepresentation influenced their envisioned career paths.
Methods
Ten UWiM family medicine trainees from one Canadian institution participated in semi-structured group interviews. Thematic analysis of the data was informed by feminist epistemology and unfolded during an iterative process of data familiarization, coding, and theme generation.
Results
Participants identified as UWiM based on visible and invisible identity markers. All participants experienced discrimination and “otherness”, but experiences differed based on how identities intersected. Participants spent considerable energy anticipating discrimination, navigating otherness, and assuming protective behaviours against real and perceived threats. Both altruism and a desire for personal safety and inclusion influenced their envisioned careers serving marginalized populations and mentoring underrepresented trainees.
Discussion
Equity, diversity, and inclusion initiatives in medical education risk being of little value without a comprehensive and intersectional understanding of the visible and invisible identities of underrepresented trainees. UWiM trainees’ accounts suggest that they experience significant identity dissonance that may result in unintended consequences if left unaddressed. Our study generated the critical awareness required for medical educators and institutions to examine their biases and meet their obligation of creating a safer and more equitable environment for UWiM trainees.
Introduction
Medical schools worldwide are creating inclusion policies to increase the admission of students from vulnerable social groups. This study explores how medical students from vulnerable social groups experience belongingness as they join the medical community.
Methods
This qualitative study applied thematic analysis to 10 interviews with medical students admitted to one medical school through an affirmative policy. The interviews followed the drawing of a rich picture, in which the students represented a challenging situation experienced in their training, considering their socio-economic and racial background. The analysis was guided by the modes of belonging ( engagement, imagination , and alignment ) described by the Communities of Practice framework.
Results
Participants struggled to imagine themselves as future doctors because they lack identification with the medical environment, suffer from low self-esteem, aside from experiencing racial and social discrimination. Participants also find it troublesome to engage in social and professional activities because of financial disadvantages and insufficient support from the university. However, participants strongly align with the values of the public health system and show deep empathy for the patients.
Discussion
Including students with different socio-economic and racial backgrounds offers an opportunity to reform the medical culture. Medical educators need to devise strategies to support students’ socialization through activities that increase their self-esteem and make explicit the contributions they bring to the medical community.
Importance
The Press Ganey Outpatient Medical Practice Survey is used to measure the patient experience. An understanding of the patient- and physician-related determinants of the patient experience may help identify opportunities to improve health care delivery and physician ratings.
Objective
To evaluate the associations between the patient experience as measured by scores on the Press Ganey survey and patient-physician racial/ethnic and gender concordance.
Design, Setting, and Participants
A cross-sectional analysis of Press Ganey surveys returned for outpatient visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. Participants included adult patient and physician dyads for whom surveys were returned. Data analysis was performed from January to June 2019.
Exposures
Patient-physician racial/ethnic and gender concordance.
Main Outcomes and Measures
The primary outcome was receipt of the maximum score for the “likelihood of your recommending this care provider to others” question in the Care Provider domain of the Press Ganey survey. Secondary outcomes included each of the remaining 9 questions in the Care Provider domain. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to investigate associations between the outcomes and patient-physician racial/ethnic and gender concordance.
Results
In total, 117 589 surveys were evaluated, corresponding to 92 238 unique patients (mean [SD] age, 57.7 [15.6] years; 37 002 men [40.1%]; 75 307 White patients [81.6%]) and 747 unique physicians (mean [SD] age 45.5 [10.6] years; 472 men [63.2%]; 533 White physicians [71.4%]). Compared with racially/ethnically concordant patient-physician dyads, discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted odds ratio [OR], 0.88; 95% CI, 0.82-0.94; P < .001). Black (adjusted OR, 0.73; 95% CI, 0.68-0.78; P < .001) and Asian (adjusted OR, 0.55; 95% CI, 0.50-0.60; P < .001) patient race were both associated with lower patient experience ratings. Patient-physician gender concordance was not associated with Press Ganey scores (adjusted OR, 1.00; 95% CI, 0.96-1.04; P = .90).
Conclusions and Relevance
In this study, higher Press Ganey survey scores were associated with racial/ethnic concordance between patients and their physicians. Efforts to improve physician workforce diversity are imperative. Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. Furthermore, Press Ganey scores may differ by a physician’s patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level.
Background:
The socioeconomic status of applicants to Canadian medical schools has been understudied in the past two decades. Institutional efforts have been made to address the lack of socioeconomic diversity across Canada during this time. We investigated the income characteristics of medical school applicants, as well as the relationship between applicant income and offer of admission, to characterize the current state of socioeconomic diversity in medical admissions.
Methods:
We conducted a retrospective cohort study on 26,120 applicants at one Ontario medical school from 2013 to 2018. Characteristics of applicants who were offered admission were compared to the general population and applicants not offered admission. Regression analyses were used to investigate the association between median total neighborhood income and successful admission.
Results:
The median total neighborhood income for medical school applicants was 28,480 higher than the Canadian general population. Those not admitted to the medical school had a median total neighborhood income of 105,984 for those offered admission (p < 0.001). This trend was seen in every province and territory in Canada. Median total neighborhood income was a predictor of an offer of admission; applicants in the >75th percentile income group had 54% increased odds of being offered admission when compared to applicants in the <25th percentile in our unadjusted model. Income was not significant in our adjusted models but showed that the income medians drastically shifted between pre-interview and post-interview periods, from 104,960 (p < 0.001).
Conclusion:
Medical school applicants are from higher economic strata compared to the general population. Despite already representing a high economic stratum, a higher median total neighborhood income relative to other applicants was associated with an offer of admission.
Background:
While the importance of medical students' demographic characteristics in influencing the scope and location of their future practice is recognized, these data are not systematically collected in Canada. This study aimed to characterize and compare the demographics of Canadian medical students with the Canadian population.
Methods:
Through an online survey, delivered in 2018, medical students at 14 English-speaking Canadian medical schools provided their age, sex, gender identity, ethnicity, educational background, and rurality of the area they grew up in. Respondents also provided information on parental income, occupation, and education as markers of socioeconomic status. Data were compared to the 2016 Canadian Census.
Results:
A total of 1388 students responded to the survey, representing a response rate of 16.6%. Most respondents identified as women (63.1%) and were born after 1989 (82.1%). Respondents were less likely, compared to the Canadian Census population, to identify as black (1.7% vs 6.4%) (P < 0.001) or Aboriginal (3.5% vs. 7.4%) (P < 0.001), and have grown up in a rural area (6.4% vs. 18.7%) (P < 0.001). Respondents had higher socioeconomic status, indicated by parental education (29.0% of respondents' parents had a master's or doctoral degree, compared to 6.6% of Canadians aged 45-64), occupation (59.7% of respondents' parents were high-level managers or professionals, compared to 19.2% of Canadians aged 45-64), and income (62.9% of respondents grew up in households with income >$100,000/year, compared to 32.4% of Canadians). Assessment of non-response bias showed that our sample was representative of all students at English-speaking Canadian medical schools with respect to age, though a higher proportion of respondents were female. Additionally, there were no differences between early and late respondents with respect to ethnicity, rurality, and parental income, occupation, and education.
Conclusions:
Canadian medical students have different socioeconomic characteristics compared to the Canadian population. Collecting and analyzing these characteristics can inform evidence-based admissions policies.
Too many First Nations, Inuit and Métis Peoples in Canada face alarming health inequities, subpar access to health care, and culturally discontinuous services — a legacy of the socio-historical realities of colonialism and racism that included systematic suppression of traditional Indigenous health knowledge and healing practices. The 2015 Calls to Action of the Truth and Reconciliation Commission of Canada underscored an urgent need for full health care rights for Indigenous Peoples, the elimination of health disparities, antiracist decolonization of the health sector, and self-determination in use of and access to traditional knowledge, therapies and healing practices. Indeed, Call to Action 22 states, “We call upon those who can effect change within the Canadian health care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients.” Indigenous knowledge and healing practices endure today, despite colonial policies and continued systematic oppression. Exemplary Indigenous-led movements that centre on traditional Indigenous knowledge have become an important feature of the Canadian medical landscape, promoting cultural activities, self determination, governance, language, medicine and wellness. With an aim to foster reconciliation efforts, we analyze unique and innovative Indigenous-led health partnerships in Canada, considering the benefits that such partnerships can hold for physicians, Indigenous communities and Canadian society more broadly.
Importance
With increasing efforts to create a diverse physician workforce that is reflective of the demographic characteristics of the US population, it remains unclear whether progress has been made since 2009, when the Liaison Committee on Medical Education set forth new diversity accreditation guidelines.
Objective
To examine demographic trends of medical school applicants and matriculants relative to the overall age-adjusted US population.
Design, Setting, and Participants
Repeated cross-sectional study of Association of American Medical Colleges data on self-reported race/ethnicity and sex of medical school applicants and matriculants compared with population distribution of the medical school–aged population (20-34 years). Data from US allopathic medical school applicants and matriculants from 2002 to 2017 were analyzed.
Main Outcomes and Measures
Trends were measured using the representation quotient, the ratio of the proportion of a racial/ethnic group in the medical student body to the general age-matched US population. Linear regression estimates were used to evaluate the trend over time for Asian, black, white, Hispanic, American Indian or Alaska Native (AIAN), and Native Hawaiian or Other Pacific Islander medical school matriculants by sex.
Results
The number of medical school applicants increased 53%, from 33 625 to 51 658, and the number of matriculants increased 29.3%, from 16 488 to 21 326, between 2002 and 2017. During that time, proportions of black, Hispanic, Asian, and Native Hawaiian or Other Pacific Islander male and female individuals aged 20 to 34 years in the United States increased, while proportions of white male and female individuals decreased and proportions of AIAN male and female individuals were stable. From 2002 to 2017, black, Hispanic, and AIAN applicants and matriculants of both sexes were underrepresented, with a significant trend toward decreased representation for black female applicants from 2002 to 2012 (representation quotient slope, −0.011; 95% CI, −0.015 to −0.007; P < .001).
Conclusions and Relevance
Black, Hispanic, and AIAN students remain underrepresented among medical school matriculants compared with the US population. This underrepresentation has not changed significantly since the institution of the Liaison Committee of Medical Education diversity accreditation guidelines in 2009. This study’s findings suggest a need for both the development and the evaluation of more robust policies and programs to create a physician workforce that is demographically representative of the US population.
Access to health care remains suboptimal for Indigenous people in Canada. One contributing factor is the longstanding undersupply of Indigenous physicians. Despite awareness of this issue, underrepresentation in medical schools continues. In 2002, Schulich School of Medicine and Dentistry (SSMD) policies were modified to enhance access for Indigenous students. This article describes our school’s continuing journey of policy and process revision, formative collaborations, early learner outcomes, and lessons learned towards this goal. In the first 10 years, SSMD matriculated 15 additional Indigenous students via this new stream. All candidates were successful in the undergraduate medical curriculum, licensing examinations, and residency match. The majority were attracted to primary care specialties, training programs affiliated with SSMD, and practices in southern Ontario. While the process and curriculum have revealed their potential, its capacity is not being maximized.
Purpose:
To describe the admissions process and outcomes for Indigenous applicants to the Northern Ontario School of Medicine (NOSM), a Canadian medical school with the mandate to recruit students whose demographics reflect the service region's population.
Method:
The authors examined 10-year trends (2006-2015) for self-identified Indigenous applicants through major admission stages. Demographics (age, sex, northern and rural backgrounds) and admission scores (grade point average [GPA], preinterview, multiple mini-interview [MMI], final), along with score-based ranks, of Indigenous and non-Indigenous applicants were compared using Pearson chi-square and Mann-Whitney tests. Binary logistic regression was used to assess the relationship between Indigenous status and likelihood of admission outcomes (interviewed, received offer, admitted).
Results:
Indigenous qualified applicants (338/17,060; 2.0%) were more likely to be female, mature (25 or older), or of northern or rural background than non-Indigenous applicants. They had lower GPA-based ranks than non-Indigenous applicants (P < .001) but had comparable preinterview-, MMI-, and final-score-based ranks across all admission stages. Indigenous applicants were 2.4 times more likely to be interviewed and 2.5 times more likely to receive an admission offer, but 3 times less likely to accept an offer than non-Indigenous applicants. Overall, 41/338 (12.1%) Indigenous qualified applicants were admitted compared with 569/16,722 (3.4%) non-Indigenous qualified applicants.
Conclusions:
Increased representation of Indigenous peoples among applicants admitted to medical school can be achieved through the use of socially accountable admissions. Further tracking of Indigenous students through medical education and practice may help assess the effectiveness of NOSM's social accountability admissions process.
Background: Choosing a suitable sample size in qualitative research is an area of conceptual debate and practical
uncertainty. That sample size principles, guidelines and tools have been developed to enable researchers to set,
and justify the acceptability of, their sample size is an indication that the issue constitutes an important marker of
the quality of qualitative research. Nevertheless, research shows that sample size sufficiency reporting is often poor,
if not absent, across a range of disciplinary fields.
Methods: A systematic analysis of single-interview-per-participant designs within three health-related journals from
the disciplines of psychology, sociology and medicine, over a 15-year period, was conducted to examine whether
and how sample sizes were justified and how sample size was characterised and discussed by authors. Data pertinent
to sample size were extracted and analysed using qualitative and quantitative analytic techniques.
Results: Our findings demonstrate that provision of sample size justifications in qualitative health research is limited; is
not contingent on the number of interviews; and relates to the journal of publication. Defence of sample size
was most frequently supported across all three journals with reference to the principle of saturation and to
pragmatic considerations. Qualitative sample sizes were predominantly – and often without justification – characterised
as insufficient (i.e., ‘small’) and discussed in the context of study limitations. Sample size insufficiency was seen
to threaten the validity and generalizability of studies’ results, with the latter being frequently conceived in nomothetic
terms.
Conclusions: We recommend, firstly, that qualitative health researchers be more transparent about evaluations of their
sample size sufficiency, situating these within broader and more encompassing assessments of data adequacy.
Secondly, we invite researchers critically to consider how saturation parameters found in prior methodological
studies and sample size community norms might best inform, and apply to, their own project and encourage
that data adequacy is best appraised with reference to features that are intrinsic to the study at hand. Finally,
those reviewing papers have a vital role in supporting and encouraging transparent study-specific reporting.
Diversity in the physician workforce lags behind the rapidly changing US population. Since the gateway to becoming a physician is medical school, diversity must be addressed in the admissions process. The Association of American Medical Colleges has implemented a Holistic Review Initiative aimed at assisting medical schools with broadening admission criteria to include relevant, mission-driven attributes and experiences in addition to academic preparation to identify applicants poised to meet the needs of a diverse patient population. More evidence is needed to determine whether holistic review results in a more diverse selection process. One of the keys to holistic review is to apply holistic principles in all stages of the selection process to ensure qualified applicants are not overlooked. This study examines whether the use of holistic review during application screening at a new medical school increased the diversity of applicants selected for interview. Using retrospective data from the first five application cycles at the Oakland University William Beaumont School of Medicine (OUWB), the author compared demographic and experiential differences between the applicants selected using holistic review, including experiences, attributes and academic metrics, to a test sample selected solely using academic metrics. The dataset consisted of the total group of applicants selected for interview in 2011 through 2015 using holistic review (n = 2773) and the same number of applicants who would have been selected for an interview using an academic-only selection model (n = 2773), which included 1204 applicants who were selected using both methods (final n = 4342). The author used a combination of cross-tabulation and analysis of variance to identify differences between applicants selected using holistic review and applicants in the test sample selected using only academics. The holistic review process yielded a significantly higher than expected percent of female (adj. resid. = 13.2, p < .01), traditionally underrepresented in medicine (adj. resid. = 15.8, p < .01), first generation (adj. resid. = 5.8, p < .01), and self-identified disadvantaged (adj resid. = 11.5, p < .01) applicants in the interview pool than selected using academic metrics alone. In addition, holistically selected applicants averaged significantly more hours than academically selected students in the areas of pre-medical school paid employment (F = 10.99, mean difference = 657.99, p < .01) and community service (F = 15.36, mean difference = 475.58, p < .01). Using mission-driven, holistic admissions criteria comprised of applicant attributes and experiences in addition to academic metrics resulted in a more diverse interview pool than using academic metrics alone. These findings add support for the use of holistic review in the application screening process as a means for increasing diversity in medical school interview pools.
Background: Despite a growing focus on the social accountability of medical schools, there has been no substantive review of admissions related to the social mission of medical schools. This paper reports on a critical scoping review of the connections between social mission and medical school admissions.
Methods: Searches of seven bibliographic databases identified 1258 unique articles. After filtering for relevance, 71 articles were considered for final review. The results of the data extraction were synthesized using a combination of qualitative and quantitative techniques.
Results: Five reviewers conducted 149 data extractions from 71 papers. Social missions tended to focus either on access and equity issues for applicants from underrepresented populations or on the career choices of medical graduates and how they meet particular social needs. The connection between social missions and admissions was often implied but rarely considered or evaluated directly. There was a notable absence of empirical evidence, with calls for reform or program descriptions far outweighing the number of papers based on empirical findings.
Conclusions: Despite the move to social missions in medical education, there remains little direct connection between missions and admissions and little evidence reflecting the efficacy or impacts of making this connection.
The concept of the social accountability of medical schools has garnered many followers, in response to a broad desire for greater social justice in health care. As its use has spread, the term 'social accountability' has become a meta-narrative for social justice and an inevitable and unquestionable good, while at the same time becoming increasingly ambiguous in its meaning and intent. In this article, we use the lenses of postmodernism and critical reflexivity to unpack the multiple meanings of social accountability. In our view, subjecting the concept of 'social accountability' to critique will enhance the ability to appraise the ways in which it is understood and enacted.
We contend that critical reflexivity is necessary for social accountability to achieve its aspirations, and hence we must be prepared to become accountable not only for our actions, but also for the ideologies and discourses underlying them.
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.
Background:
The Multiple Mini-Interview (MMI) has been used increasingly for selection of students to health professions programmes.
Objectives:
This paper reports on the evidence base for the feasibility, acceptability, reliability and validity of the MMI.
Data sources:
CINAHL and MEDLINE STUDY ELIGIBILITY CRITERIA: All studies testing the MMI on applicants to health professions training.
Study appraisal and synthesis methods:
Each paper was appraised by two reviewers. Narrative summary findings on feasibility, acceptability, reliability and validity are presented.
Results:
Of the 64 citations identified, 30 were selected for review. The modal MMI consisted of 10 stations, each lasting eight minutes and assessed by one interviewer. The MMI was feasible, i.e. did not require more examiners, did not cost more, and interviews were completed over a short period of time. It was acceptable, i.e. fair, transparent, free from gender, cultural and socio-economic bias, and did not favour applicants with previous coaching. Its reliability was reported to be moderate to high, with Cronbach's alpha = 0.69-0.98 and G = 0.55-0.72. MMI scores did not correlate to traditional admission tools scores, were not associated with pre-entry academic qualifications, were the best predictor for OSCE performance and statistically predictive of subsequent performance at medical council examinations.
Conclusions:
The MMI is reliable, acceptable and feasible. The evidence base for its validity against future medical council exams is growing with reports from longitudinal investigations. However, further research is needed for its acceptability in different cultural context and validity against future clinical behaviours.
Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
Although a multiplicity of qualities and behaviours considered essential in a good doctor are identified in the profession's guidance documents, there is no consensus as to their relative importance, or indeed, agreement as to the core qualities that should be, or could be, feasibly assessed in the limited time of the typical medical school interview.
The aim of the study was to identify the most important generic attributes of good doctors, which can inform the content of the undergraduate medical student selection processes.
The study used a Delphi survey to systematically gather the opinion of a panel of experts from a range of medical specialties as to the most important core attributes of good doctors. Additionally, a snapshot of opinion was obtained from the attendees of workshops held at a medical school educational conference.
Common core attributes of a good doctor were identified across a number of medical specialties.
Consensus among clinicians from disparate specialties can be reached as to the most important generic attributes of good doctors and can be used to inform the choice of personal qualities and behaviours examined during undergraduate medical student selection process.
Multiple mini-interviews (MMIs) are increasingly used in high-stakes medical school selection. Yet there is little published research about participants' experiences and understandings of the process. We report the findings from an international qualitative study on candidate and interviewer experiences of the MMI for entry into a graduate-entry medical school.
Qualitative data from six interviewer focus groups and 442 candidate and 75 interviewer surveys were analysed using framework analysis. Multiple researchers (n = 3) analysed a proportion of the data and developed a thematic framework capturing content-related (i.e. what was said) themes that emerged from the data. This thematic framework was then used to code the complete dataset.
Several key themes were identified, including participants' perspectives on having: (i) a one-to-one interview; (ii) multiple assessment opportunities; (iii) a standardised, scenario-based interview; (iv) a mini-interview, and on (v) the attributes currently measured by the MMI, and (vi) other attributes that should be assessed.
We gained a deeper understanding of participants' experiences of a high-stakes, decision-making process for selection into a graduate-entry medical school. We discuss our findings in the light of the existing literature and make recommendations to address the issue of differing participant expectations and understandings of the MMI, and to improve the credibility and acceptability of the process.
The demographic and socioeconomic profile of medical school classes has implications for where people choose to practise and whether they choose to treat certain disadvantaged groups. We aimed to describe the demographic and socioeconomic characteristics of first-year Canadian medical students and compare them with those of the Canadian population to determine whether there are groups that are over- or underrepresented. Furthermore, we wished to test the hypothesis that medical students often come from privileged socioeconomic backgrounds.
As part of a larger Internet survey of all students at Canadian medical schools outside Quebec, conducted in January and February 2001, first-year students were asked to give their age, sex, self-described ethnic background using Statistics Canada census descriptions and educational background. Postal code at the time of high school graduation served as a proxy for socioeconomic status. Respondents were also asked for estimates of parental income and education. Responses were compared when possible with Canadian age-group-matched data from the 1996 census.
Responses were obtained from 981 (80.2%) of 1223 first-year medical students. There were similar numbers of male and female students (51.1% female), with 65% aged 20 to 24 years. Although there were more people from visible minorities in medical school than in the Canadian population (32.4% v. 20.0%) (p < 0.001), certain minority groups (black and Aboriginal) were underrepresented, and others (Chinese, South Asian) were overrepresented. Medical students were less likely than the Canadian population to come from rural areas (10.8% v. 22.4%) (p< 0.001) and were more likely to have higher socioeconomic status, as measured by parents' education (39.0% of fathers and 19.4% of mothers had a master's or doctoral degree, as compared with 6.6% and 3.0% respectively of the Canadian population aged 45 to 64), parents' occupation (69.3% of fathers and 48.7% of mothers were professionals or high-level managers, as compared with 12.0% of Canadians) and household income (15.4% of parents had annual household incomes less than 160,000, as compared with 2.7% of Canadian households with an income greater than $150,000). Almost half (43.5%) of the medical students came from neighbourhoods with median family incomes in the top quintile (p < 0.001). A total of 57.7% of the respondents had completed 4 years or less of postsecondary studies before medical school, and 29.3% had completed 6 or more years. The parents of the medical students tended to have occupations with higher social standing than did working adult Canadians; a total of 15.6% of the respondents had a physician parent.
Canadian medical students differ significantly from the general population, particularly with regard to ethnic background and socioeconomic status.
To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school.
Focus group study.
Six London secondary schools.
68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds.
Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support.
There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards "posh" students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfillment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices.
Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.
To explore the medical school experiences of students who self-identify as coming from a working-class or impoverished family background.
A questionnaire was administered to Year 3 medical students at a Canadian medical school and in-depth interviews were held with 25 of these students (cohort 1). The same methods were repeated with another Year 3 class 3 years later (cohort 2).
While having (or not having) money was the most obvious impact of social class differences, students also discussed more subtle signs of class that made it easier or more difficult to fit in at medical school. Students from working-class or impoverished backgrounds were significantly less likely to report that they fitted in well, and more likely to report that their class background had a negative impact in school. They were also more likely to indicate awareness that a patient's social class may affect their health care treatment.
Students from working-class or impoverished backgrounds may experience alienation in medical school. Through the commonplace interactions of 'everyday classism' they may experience marginalisation, isolation, disrespect and unintentional slights. At the same time, they suggest that their experiences of exclusion may strengthen their clinical practice.
Introduction:
Many medical schools have well-established admission pathways and programing to support Indigenous medical workforce development. Ideally, these efforts should contribute to attracting highly qualified Indigenous applicants which, in turn, may improve accessible, quality care for Indigenous people. However, it is difficult to evolve and tailor these approaches without a situated understanding of Indigenous learners' experiences. In this paper we focus on the Canadian context, sharing Indigenous learners' stories about their journey towards and throughout medical training.
Methods:
The conceptual underpinnings of narrative inquiry and key principles from Indigenous methodologies were drawn upon throughout both data collection and analysis. Participants were Indigenous learners (medical students and residents) and a recently graduated physician (n=5) from one Canadian medical school. Both spoken (formal recorded interviews) and visual (photographs) texts were used to make meaning of participants' experiences.
Results:
Participants' experiences during medical training showed a striking resemblance at three points in their transition to, and progression through, medical education: preparing for and applying to medical school, completing undergraduate medical training, and determining specialty choice. Participants' stories revealed a tug-of-war between their identities as an Indigenous person and as a medical trainee, with these tensions sometimes compromising their perceived sense of belonging within both Indigenous and academic circles, creating, at times, a heavy burden to shoulder.
Conclusion:
Meaningful representation of Indigenous people in the medical workforce is about more than training additional healthcare providers; it requires understanding Indigenous learners and recently graduated physicians' experiences as they enter and navigate the medical profession. By amplifying their voices, we stand to gain a more holistic representation of the factors that contribute to and potentially impede the recruitment and retention of Indigenous people into the medical profession.
As health and social service professions increasingly emphasize commitments to equity, advocacy and social justice, non-traditional entrants to the professions increasingly bring much-needed diversity of social backgrounds and locations. Long the domain of elite social classes, the professions are not always welcoming cultures for those from lower social class backgrounds. This paper draws on notions of material, social and cultural capital, along with habitus, to examine the experiences of professionals with lower-class backgrounds, in educational programs and in their professions. The critical interpretive qualitative study draws on interviews with 27 professionals across Canada in medicine, nursing, social work and occupational therapy. While participants were clearly set apart from their colleagues by class origins, which posed distinct struggles, they also brought valuable assets to their work: enhanced connection and rapport with clients/patients, approachability, structural analysis and advocacy, plus nuanced re-envisioning of professional ethics to minimize power dichotomies. Rather than helping lower-class entrants adapt to the professions, it may be more beneficial to alter normative professional cultures to better suit these practitioners.
Context:
Without volunteer interviewers, many universities would not be able to run multiple mini interviews (MMIs) due to the prohibitive cost of paying interviewers. Despite the opportunity cost borne by volunteers, many interviewers participate in multiple MMI sessions per year, and volunteer year after year. There is surprisingly little research into what motivates interviewers to volunteer as MMI interviewers. This research aims to explore both what motivates individuals to volunteer to interview in MMIs for undergraduate medical selection, and what adds and detracts value from their participation.
Methods:
We applied a qualitative sequential two-phase design consisting of open-ended survey questions, followed by semi-structured interviews to explore interviewers' motivators in more depth. The survey data on motivators and the six functions from the Volunteer Functions Inventory (VFI) informed interview data collection and provided a lens through which to examine MMI interviewer motivations. Content analysis was used to analyse the survey data. Framework analysis was used to analyse the interview data.
Results:
The survey was completed by 108 interviewers (50% response rate), and 19 semi-structured interviews were conducted (54% response rate). From the content analysis the time commitment of involvement was the biggest detractor identified by participants. Through the framework analysis five overarching motivators were developed: i) acting on values, ii) gaining understanding, iii) gaining personal satisfaction and gratification, iv) shaping the future workforce, and v) having social interaction. These mirrored five of the six functions proposed in the VFI.
Conclusions:
There are a range of motivating factors that influenced the participants' decision to volunteer as an interviewer for MMIs. Some motivations were for the benefit of others, some were self-serving, and some a combination of both. Universities should utilise these motivating factors to aid in targeted recruitment of volunteer interviewers.
Issue
Practices of systemic and structural racism that advantage some groups over others are embedded in American society. Institutions of higher learning are increasingly being pressured to develop strategies that effectively address these inequities. This article examines medical education’s diversity reforms and inclusion practices, arguing that many reify preexisting social hierarchies that privilege white individuals over those who are minoritized because of their race/ethnicity. Evidence: Drawing on the work of French theorist Michel Foucault, we argue that medical education’s curricular and institutional practices reinforce asymmetrical power differences and authority in ways that disadvantage minoritized individuals. Practices, such as medical education’s reliance on biomedical approaches, cultural competency, and standardized testing reinforce a racist system in ways congruent with the Foucauldian concept of “normalization.” Through medical education’s creation of subjects and its ability to normalize dominant forms of knowledge, trainees are shaped and socialized into ways of thinking, being, and acting that continue to support racial violence against minoritized groups. The systems, structures, and practices of medical education need to change to combat the pervasive forces that continue to shape racist institutional patterns. Individual medical educators will also need to employ critical approaches to their work and develop strategies that counteract institutional systems of racial violence. Implications: A Foucauldian approach that exposes the structural racism inherent in medical education enables both thoughtful criticism of status-quo diversity practices and practical, theory-driven solutions to address racial inequities. Using Foucault’s work to interrogate questions of power, knowledge, and subjectivity can expand the horizon of racial justice reforms in medicine by attending to the specific, pervasive ways racial violence is performed, both intra- and extra-institutionally. Such an intervention promises to take seriously the importance of anti-racist methodology in medicine.
The conceptualisation of “good” medical education research as hypothesis testing to identify universal truths that are generalisable across contexts has been challenged. Joining this conversation, the field of health professions education research is complex and contextual and there are ways of examining and reporting locally based activities and innovations which can be of general value. This position leads to a focus on case study research (CSR); inquiry bound in time and place that generates thick descriptions and close interpretations to reach explanations. CSR has grown in sophistication in recent years and can inform practice and advance the science of medical and health professions education. The authors evaluated the current state of the science of CSR in the medical education literature by identifying and reviewing 160 papers. Most articles presented as “case studies” were not in fact CSR. Moreover, most articles failed to go beyond a ‘we did this’ account. The authors explore definitions of CSR, they examine dominant CSR methodologists, Yin, Stake and Merriam, and their respective approaches to CSR. They then set out some of the basic tenets of CSR (case definition, methods of data collection and analysis) and consider the logics of CSR (its structures, purposes, assumptions and symbols). CSR challenges are considered next (such as emic and etic perspectives; ethical complexities; generalizability; quality; and reporting and reflexivity. The authors conclude that context is a mechanism which needs to be understood and rigorous CSR provides the structures and criticality to do so, opening up new areas of understanding and inquiry.
Structural racism is pervasive in U.S. society, and academic medicine is not immune to the effects of this disease. The social determinants of health have been implicated as the main drivers of health disparities and inequities in society, and racism has been well-established as a social determinant of health. Research consistently highlights poor health outcomes for Black populations and other communities of color compared with White populations across a variety of conditions. Medical students, residents, and faculty of all backgrounds regularly experience the destructive effects of structural racism in medicine. Renewed attention to the problem is encouraging, but, if it is consistent with history, transient. If academic medicine can arrive at a place of discarding the shackles of biological determinism, perhaps the field can begin to take initial steps toward dismantling the structural racism that drives health inequities. To make true headway, academic medicine must be willing to make bold strategic and financial commitments to do more. This work will not be easy, and there will be great resistance to the type of change that is needed. It is time to ask whether the leaders of academic institutions have the will to act and to continue to push forward in the face of opposition. The author is skeptical-because of the scope of the work that needs to be done and because it feels as if society has been here many times before-and, yet, remains optimistic.
Background:
We examine the cultural myth of the medical meritocracy, whereby the "best and the brightest" are admitted and promoted within the profession. We explore how this narrative guides medical practice in ways that may no longer be adequate in the contexts of practice today.
Methods:
Narrative analysis of medical students' and physicians' stories.
Results:
Hierarchies of privilege within medicine are linked to meritocracy and the trope of the "hero's story" in literature. Gender and other forms of difference are generally excluded from narratives of excellence, which suggests operative mechanisms that may be contributory to observed differences in attainment. We discuss how the notion of diversity is formulated in medicine as a "problem" to be accommodated within merit, and posit that medical practice today requires a reformulation of the notion of merit in medicine, valorising a diversity of life experience and skills, rather than "retrofitting" diversity concerns as problems to be accommodated within current constructs of merit.
Conclusions:
Three main action-oriented outcomes for a better formulation of merit relevant to medical practice today are suggested: (a) development of assessors' critical consciousness regarding the structural issues in merit assignment; (b) alignment of merit criteria with relevant societal outcomes, and (c) developing inclusive leadership to accommodate the greater diversity of excellence needed in today's context of medical practice. A reformulation of the stories through which medical practitioners and educators communicate and validate aspects of medical practice will be required in order for the profession to continue to have relevance to the diverse societies it serves.
This article discusses a sociocultural approach we have developed, which we refer to as funds of knowledge. The emphasis of the funds of knowledge work has been to develop both theory and methods through which educators can approach and document the funds of knowledge of families and re-present them on the bases of the knowledge, resources, and strengths they possess, thus challenging deficit orientations that are so dominant, in particular, in the education of working-class children. In this article, I present a translocation view of funds of knowledge and what we can learn theoretically and methodologically from this body of work. I review four studies conducted in different countries and sociocultural contexts. In each context, the researchers reorient the concept of funds of knowledge to address issues germane to their settings. The four studies from New Zealand, Spain, Australia, and Uganda used funds of knowledge to generate new ideas and positionalities regarding work with teachers, students, and families. None of the projects simply replicated the original studies conducted in the United States. The four studies documented empirically and represent pedagogically families and students as resourceful and helped educators arrange environments that are academically sound and strongly oriented to building on such resources for learning.
Those in medical education have a responsibility to prepare a physician workforce that can serve increasingly diverse communities, encourage healthy changes in patients, and advocate for the social changes needed to advance the health of all. The authors of this Perspective discuss many of the likely causes of the observed differences in mean Medical College Admission Test (MCAT) scores between students from groups well represented in medicine and those from groups underrepresented in medicine. The lower mean MCAT scores of underrepresented groups can present challenges to diversifying the physician workforce if medical schools only admit those applicants with the highest MCAT scores. The authors review the psychometric literature, which showed no evidence of bias in the exam, and note that the differences in mean MCAT scores between racial and ethnic groups are similar to those in other measures of academic achievement and performance on high-stakes tests.
The authors then describe the ways in which structural racism in the United States has contributed to differences in achievement for underrepresented students compared with well-represented students. These differences are not due to differences in aptitude but to differences in opportunities. The authors describe the widespread consequences of structural racism on economic success, educational opportunity, and bias in the educational environment. They close with 3 recommendations for medical schools that may mitigate the consequences of structural racism while maintaining academic standards and admitting students likely to succeed. Adopting these recommendations may help the medical profession build the diverse physician workforce needed to serve communities today.
Approach:
This qualitative study utilized a grounded theory approach. Between December 2012 and January 2014, the principal researcher conducted one-on-one telephone and in-person small-group interviews, as well as web-based telephone feedback sessions, with Black/African American and Hispanic/Latino medical students.
Findings:
Thirty-three students participated, including 23 Black/African American and 10 Hispanic/Latino medical students. Participants represented 25 U.S. allopathic medical schools. Emergent themes are categorized under 2 headings: (a) motivations for a career in medicine and (b) barriers and supports. Motivations for a career in medicine include perceived fit, prior experience or knowledge, encouragement and role models, desire to help others, interest in science, and perceived benefits. Barriers and supports included information, guidance and social support, financial and academic factors, and persistence. Insights: Building on theories of student college choice and academic capital formation, the researcher's analysis and interpretations result in the proposal of a conceptual model describing minority applicants' experience in medical school admissions. The study also suggests research and practice implications related to premedical advising, mentoring, financial assistance, information, outreach, and data collection.
"Community" has featured in the discourse about medical education for over half a century. This discourse has explored relationships between medical education programs and communities in community-oriented medical education and community-based medical education and, in recent years, has extended to community-engaged medical education (CEME). This Perspective explores the developing focus on "community" in medical education, describes CEME as a concept, and presents examples of CEME in action at Flinders University School of Medicine (Australia), the Northern Ontario School of Medicine (Canada), and Ateneo de Zamboanga University School of Medicine (Philippines).The authors describe the ways in which CEME, which features active community participation, can improve medical education while meeting community needs and advancing national and international health equity agendas. They suggest that CEME can redefine student learning as taking place at the center of the partnership between communities and medical schools. They also consider the challenges of CEME and caution that criteria for community engagement must be sensitive to cultural variations and to the nature of the social contract in different sociocultural settings.The authors argue that CEME is effective in producing physicians who choose to practice in rural and underserved areas. Further research is required to demonstrate that CEME contributes to improved health, and ultimately health equity, for the populations served by the medical school.
How to best select future doctors and the implications of selection for equity and access are timely, relevant, and complex issues that fundamentally affect other aspects of medical education such as curriculum design and social accountability. The authors thus conducted an environmental scan of practices related to access and selection in Canadian medical schools.
The authors drew and built on a literature review, key informant interviews, and expert panel discussions conducted as part of the 2008-2009 Future of Medical Education in Canada project to detail the empirical basis for prioritizing the study of access and selection, the evidence base of current practices, and implications for medical schools.
Data clustered around four principles: (1) selection criteria must address current attributes and future potential, (2) access to medical school and diversity within the class are linked to a school's social accountability framework, (3) sound instruments and protocols are necessary to maximize reliability and validity, and (4) medical schools must be accountable for the effectiveness of their admissions processes. Although initiatives addressing barriers exist, ongoing challenges include recruitment and selection for overall diversity, adoption of better criteria for nonacademic achievement, and empirical validation of selection processes.
Evidence-based selection processes can optimize the provision of broadly competent physicians for a given population. Schools must work to minimize systematic barriers for specific groups. Although this analysis provides a Canadian perspective, the principles and implications are relevant to medical education institutions elsewhere.
Background: The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce. Objective: To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions. Design: Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the Association of American Colleges of Osteopathic Medicine. Setting: U.S. medical schools. Participants: 60 043 physicians in active practice who graduated from medical school between 1999 and 2001. Measurements: The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score. Results: The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non-community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas. Limitations: The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates. The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates. Conclusion: Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities. Primary Funding Source: Josiah Macy, Jr. Foundation.
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.
Context:
Socially accountable medical schools aim to reduce health inequalities by training workforces responsive to the priority health needs of underserved communities. One key strategy involves recruiting students from underserved and unequally represented communities on the basis that they may be more likely to return and address local health priorities. This study describes the impacts of different selection strategies of medical schools that aspire to social accountability on the presence of students from underserved communities in their medical education programmes and on student practice intentions.
Methods:
A cross-sectional questionnaire was administered to students starting medical education in five institutions with a social accountability mandate in five different countries. The questionnaire assessed students' background characteristics, rurality of background, and practice intentions (location, discipline of practice and population to be served). The results were compared with the characteristics of students entering medical education in schools with standard selection procedures, and with publicly available socio-economic data.
Results:
The selection processes of all five schools included strategies that extended beyond the assessment of academic achievement. Four distinct strategies were identified: the quota system; selection based on personal attributes; community involvement, and school marketing strategies. Questionnaire data from 944 students showed that students at the five schools were more likely to be of non-urban origin, of lower socio-economic status and to come from underserved groups. A total of 407 of 810 (50.2%) students indicated an intention to practise in a non-urban area after graduation and the likelihood of this increased with increasing rurality of primary schooling (p = 0.000). Those of rural origin were statistically less likely to express an intention to work abroad (p = 0.003).
Conclusions:
Selection strategies to ensure that members of underserved communities can pursue medical careers can be effective in achieving a fair and equitable representation of underserved communities within the student body. Such strategies may contribute to a diverse medical student body with strong intentions to work with underserved populations.
Purpose:
To investigate current medical school admission processes and whether they differ from those in 1986 when they were last reviewed by the Association of American Medical Colleges (AAMC).
Method:
In spring 2008, admission deans from all MD-granting U.S. and Canadian medical schools using the Medical College Admission Test (MCAT) were invited to complete an online survey that asked participants to describe their institution's admission process and to report the use and rate the importance of applicant data in making decisions at each stage.
Results:
The 120 responding admission officers reported using a variety of data to make decisions. Most indicated using interviews to assess applicants' personal characteristics. Compared with 1986, there was an increase in the emphasis placed on academic data during pre-interview screening. While GPA data were among the most important data in decision making at all stages in 1986, data use and importance varied by the stage of the process in 2008: MCAT scores and undergraduate GPAs were rated as the most important data for deciding whom to invite to submit secondary applications and interview, whereas interview recommendations and letters of recommendation were rated as the most important data in deciding whom to accept.
Conclusions:
This study underscores the complexity of the medical school admission process and suggests increased use of a holistic approach that considers the whole applicant when making admission decisions. Findings will inform AAMC initiatives focused on transforming admission processes.
The Medical College Admission Test (MCAT) is a standardized examination that assesses fundamental knowledge of scientific concepts, critical reasoning ability, and written communication skills. Medical school admission officers use MCAT scores, along with other measures of academic preparation and personal attributes, to select the applicants they consider the most likely to succeed in medical school. In 2008-2011, the committee charged with conducting a comprehensive review of the MCAT exam examined four issues: (1) whether racial and ethnic groups differ in mean MCAT scores, (2) whether any score differences are due to test bias, (3) how group differences may be explained, and (4) whether the MCAT exam is a barrier to medical school admission for black or Latino applicants.This analysis showed that black and Latino examinees' mean MCAT scores are lower than white examinees', mirroring differences on other standardized admission tests and in the average undergraduate grades of medical school applicants. However, there was no evidence that the MCAT exam is biased against black and Latino applicants as determined by their subsequent performance on selected medical school performance indicators. Among other factors which could contribute to mean differences in MCAT performance, whites, blacks, and Latinos interested in medicine differ with respect to parents' education and income. Admission data indicate that admission committees accept majority and minority applicants at similar rates, which suggests that medical students are selected on the basis of a combination of attributes and competencies rather than on MCAT scores alone.
Background
Communication of lung cancer risk information between providers and African-American patients occurs in a context marked by race-based health disparities.
Purpose
A controlled experiment assessed whether perceived physician race influenced African-American patients’ (n = 127) risk perception accuracy following the provision of objective lung cancer risk information.
Methods
Participants interacted with a virtual reality-based, simulated physician who provided personalized cancer risk information.
Results
Participants who interacted with a racially discordant virtual doctor were less accurate in their risk perceptions at post-test than those who interacted with a concordant virtual doctor, F(1,94) = 4.02, p = .048. This effect was amplified among current smokers. Effects were not mediated by trust in the provider, engagement with the health care system, or attention during the encounter.
Conclusions
The current study demonstrates that African-American patients’ perceptions of a doctor’s race are sufficient to independently impact their processing of lung cancer risk information.
Purpose:
Policy groups recommend monitoring and supporting more diversity among medical students and the medical workforce. In Canada, few data are available regarding the diversity of medical students, which poses challenges for policy development and evaluation. The authors examine diversity through a framework of surface (visible) and deep (less visible) dimensions and present data regarding a sample of Canadian medical students.
Method:
Between 2009 and 2011, nine cohorts from four Canadian medical schools completed the Health Professions Student Diversity Survey (HPSDS) either on paper or online. Items asked each participant's age, gender, gender identity, sexual identity, marital status, ethnicity, rural status, parental income, and disability. Data were analyzed descriptively and compared, when available, with national data.
Results:
Of 1,892 students invited, 1,552 (82.0%) completed the HPSDS. Students tended to be 21 to 25 years old (68.3%; 1,048/1,534), female (59.0%; 902/1,529), heterosexual (94.6%; 1,422/1,503), single (90.1%; 1,369/1,520), and unlikely to report any disability (96.5%; 1,463/1,516). The majority of students identified with the gender on their birth certificate (99.8%; 1,512/1,515). About half had spent the majority of their lives in urban environments (46.7%; 711/1,521), and most reported parental household incomes of over $100,000/year (57.6%; 791/1,373). Overall, they were overrepresentative of higher-income groups and underrepresentative of populations of Aboriginal, black, or Filipino ethnicities in Canada.
Conclusions:
The authors propose the development of a National Student Diversity Database to support both locally relevant policies regarding pipeline programs and an examination of current application and selection procedures to identify potential barriers for underrepresented students.
The McGill University Faculty of Medicine undertook a pilot, simulation-based multiple mini-interview (MMI) for medical school applicant selection, which ran simultaneously with traditional unstructured interviews (all applicants underwent both processes). This paper examines major stakeholder (applicants and evaluators) opinions towards the MMI compared with traditional interviews, including perceptions about the feasibility and utility of the MMI.
A total of 100 candidates applying to McGill University Medical School were enrolled in the pilot comparison of the MMI with the traditional, unstructured interview. Applicants' opinions were obtained by questionnaire shortly after the process (for all applicants) and approximately 6 months after the interviews (for non-accepted applicants). Evaluators' perceptions were also surveyed. Questionnaires contained both quantitative items and space for qualitative impressions. Descriptive statistics, repeated measures analysis of variance (manova) and analysis of the topics raised in written comments were conducted.
Univariate analyses of response scores revealed statistically significant differences, with the MMI rated more highly than the traditional interview on fairness, imposition of stress and effectiveness as a measurement tool. Compared with the traditional interview, applicants also felt the MMI: (i) allowed them to be competitive; (ii) was enjoyable, and (iii) was often a favourite part of their interview experience. It should be noted that applicants were aware that their MMI score would be included in their overall interview rating. Written comments were positive with regard to, for example, fairness, the provision of opportunities to show one's strengths, and appreciation of the fidelity of the simulations. Evaluators' responses were in agreement with applicants' responses, albeit that overall they expressed more caution about the MMI.
Results suggest the MMI is a promising selection tool from the point of view of both applicants and evaluators. Both groups expressed concerns, but overall the response was favourable for the MMI in comparison with traditional interviews, and the MMI has been adopted by McGill University's medical school.
In this paper we report on further tests of the validity of the multiple mini-interview (MMI) selection process, comparing MMI scores with those achieved on a national high-stakes clinical skills examination. We also continue to explore the stability of candidate performance and the extent to which so-called 'cognitive' and 'non-cognitive' qualities should be deemed independent of one another.
To examine predictive validity, MMI data were matched with licensing examination data for both undergraduate (n = 34) and postgraduate (n = 22) samples of participants. To assess the stability of candidate performance, reliability coefficients were generated for eight distinct samples. Finally, correlations were calculated between 'cognitive' and 'non-cognitive' measures of ability collected in the admissions procedure, on graduation from medical school and 18 months into postgraduate training.
The median reliability of eight administrations of the MMI in various cohorts was 0.73 when 12 10-minute stations were used with one examiner per station. The correlation between performance on the MMI and number of stations passed on an objective structured clinical examination-based licensing examination was r = 0.43 (P < 0.05) in a postgraduate sample and r = 0.35 (P < 0.05) in an undergraduate sample of subjects who sat the MMI 5 years prior to sitting the licensing examination. The correlation between 'cognitive' and 'non-cognitive' assessment instruments increased with time in training (i.e. as the focus of the assessments became more tailored to the clinical practice of medicine).
Further evidence for the validity of the MMI approach to making admissions decisions has been provided. More generally, the reported findings cast further doubt on the extent to which performance can be captured with trait-based models of ability. Finally, although a complementary predictive relationship has consistently been observed between grade point average and MMI results, the extent to which cognitive and non-cognitive qualities are distinct appears to depend on the scope of practice within which the two classes of qualities are assessed.
Although health sciences programmes continue to value non-cognitive variables such as interpersonal skills and professionalism, it is not clear that current admissions tools like the personal interview are capable of assessing ability in these domains. Hypothesising that many of the problems with the personal interview might be explained, at least in part, by it being yet another measurement tool that is plagued by context specificity, we have attempted to develop a multiple sample approach to the personal interview.
A group of 117 applicants to the undergraduate MD programme at McMaster University participated in a multiple mini-interview (MMI), consisting of 10 short objective structured clinical examination (OSCE)-style stations, in which they were presented with scenarios that required them to discuss a health-related issue (e.g. the use of placebos) with an interviewer, interact with a standardised confederate while an examiner observed the interpersonal skills displayed, or answer traditional interview questions.
The reliability of the MMI was observed to be 0.65. Furthermore, the hypothesis that context specificity might reduce the validity of traditional interviews was supported by the finding that the variance component attributable to candidate-station interaction was greater than that attributable to candidate. Both applicants and examiners were positive about the experience and the potential for this protocol.
The principles used in developing this new admissions instrument, the flexibility inherent in the multiple mini-interview, and its feasibility and cost-effectiveness are discussed.
A major expense for most professional training programs, both financially and in terms of human resources, is the interview process used to make admissions decisions. Still, most programs view this as a necessary cost given that the personal interview provides an opportunity to recruit potential candidates, showing them what the program has to offer, and to try and gather more information about the candidates to ensure that those selected live up to the espoused values of the institution. We now have five years worth of experience with a Multiple Mini-Interview (MMI) process that, unlike traditional panel interviews, uses the OSCE model to have candidates interact with a larger number of interviewers. We have found that the MMI is more reliable and has better predictive power than our traditional panel interviews. Still, the extent to which any measurement is valuable depends also on the feasibility of use. In this paper we report on an exploration of the cost effectiveness of the MMI as compared to standard panel-based interviews by considering the generation of interview material, human resource (i.e., interviewer and support staff) use, infrastructure requirements, and other miscellaneous expenses. Our conclusion is that the MMI requires greater preparatory efforts and a larger number of rooms to carry out the interviews relative to panel-based interviews, but that these cost disadvantages are offset by the MMI requiring fewer person-hours of effort. The absolute costs will vary dependent on institution, but the framework presented in this paper will hopefully provide greater guidance regarding logistical requirements and anticipated budget.
The Multiple Mini-Interview (MMI) has previously been shown to have a positive correlation with early medical school performance. Data have matured to allow comparison with clerkship evaluations and national licensing examinations.
Of 117 applicants to the Michael G DeGroote School of Medicine at McMaster University who had scores on the MMI, traditional non-cognitive measures, and undergraduate grade point average (uGPA), 45 were admitted and followed through clerkship evaluations and Part I of the Medical Council of Canada Qualifying Examination (MCCQE). Clerkship evaluations consisted of clerkship summary ratings, a clerkship objective structured clinical examination (OSCE), and progress test score (a 180-item, multiple-choice test). The MCCQE includes subsections relevant to medical specialties and relevant to broader legal and ethical issues (Population Health and the Considerations of the Legal, Ethical and Organisational Aspects of Medicine[CLEO/PHELO]).
In-programme, MMI was the best predictor of OSCE performance, clerkship encounter cards, and clerkship performance ratings. On the MCCQE Part I, MMI significantly predicted CLEO/PHELO scores and clinical decision-making (CDM) scores. None of these assessments were predicted by other non-cognitive admissions measures or uGPA. Only uGPA predicted progress test scores and the MCQ-based specialty-specific subsections of the MCCQE Part I.
The MMI complements pre-admission cognitive measures to predict performance outcomes during clerkship and on the Canadian national licensing examination.
Holistic admissions in higher education: a systematic literature review
- J M Maude
- D Kirby
Maude JM, Kirby D. 2022. Holistic admissions in higher education: a
systematic literature review. J Higher Educ Theory and Pract. 22(8):
73-80. doi: 10.33423/jhetp.v22i8.5317.
When I say … intersectionality in medical education research
- L V Monrouxe
Monrouxe LV. 2015. When I say … intersectionality in medical education research. Med Educ. 49(1):21-22. doi: 10.1111/medu.1242.