Taking context seriously: explaining widening access policy enactments in UK medical schools

Front row seat: The role MMI assessors play in widening access to medical school

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.

The maintenance of classism in medical education: "time" as a form of social capital in first-generation and low-income medical students

As first generation (FG)/low income (LI) students enter the elite profession of medicine, schools make presumptions about how FGLI students allocate their time. However, their lives are markedly different compared to their peers. This study argues that while all forms of capital are necessary for success, time as a specific form keeps classism in place. Using constructivist grounded theory techniques, we interviewed 48 FGLI students to understand where, why and how they allocated their time, and the perceived impact it had on them. Using open coding and constant comparison, we developed an understanding of FGLI students' relationship to time and then contextualized it within larger conversations on how time is conceptualized in a capitalist system that demands time efficiency, and the activities where time is needed in medical school. When students discussed time, they invoked the concept of 'time famine;' having too much to do and not enough time. In attempting to meet medicine's expectations, they conceptualized time as something that was 'spent' or 'given/taken' as they traversed different marketplaces, using their time as a form of currency to make up for the social capital expected of them. This study shows that because medical education was designed around the social elite, a strata of individuals who have generational resources, time is a critical aspect separating FGLI students from their peers. This study undergirds the idea that time is a hidden organizational framework that helps to maintain classism, thus positioning FGLI students at a disadvantage.

Follow the policy: An actor network theory study of widening participation to medicine in two countries

INTRODUCTION

The slow pace of change in respect of increasing the diversity of medical students suggests powerful actors are reproducing practices to support the status quo. Opening up medicine to embrace diversity thus requires the deconstruction of entrenched processes and practices. The first step in doing so is to understand how the actor-network of widening participation and access to medicine (WP/WA) is constructed. Thus, here we examine how the connections among actors in WP/WA in two different networks are assembled.

METHODS

A comparative case study using documents (n = 7) and interviews with staff and students (n = 45) from two medical schools, one United Kingdom and one Australian, was used. We used Callon's moments of translation (problematisation, interessement/operationalisation, enrolment, mobilisation) to map the network of actors as they are assembled in relation to one another. Our main actant was institutional WP to medicine policy (actor-as-policy).

RESULTS

Our actor-as-policy introduced five other actors: the medical school, medical profession, high schools, applicants and medical school staff. In terms of problematisation, academic excellence holds firm as the obligatory passage point and focal challenge for all actors in both countries. The networks are operationalised via activities such as outreach and admissions policy (e.g., affirmative action is apparent in Australia but not the UK). High schools play (at best) a passive role, but directed by the policy, the medical schools and applicants work hard to achieve WP/WA to medicine. In both contexts, staff are key mobilisers of WP/WA, but with little guidance in how to enact policy. In Australia, policy drivers plus associated entry structures mean the medical profession exerts significant influence.

CONCLUSIONS

Keeping academic excellence as the obligatory passage point to medical school shapes the whole network of WP/WA and perpetuates inequality. Only by addressing this can the network reconfigure.

Demographic disparities in dental school selection: An analysis of current UK practices

INTRODUCTION

Specific social groups remain under-represented within dentistry. While the University Clinical Aptitude Test (UCAT) aims to widen participation in under-represented social groups, there is no evidence in dental education that this aim is being met.

MATERIALS AND METHODS

Data over two admission cycles (2012 and 2013), including 3246 applicants to 10 UK dental schools, were analysed. Applicant and selected pools were compared to the UK population. Multiple logistic regression was used to investigate the association between demographic variables and UCAT and receiving an offer of a place at dental school.

RESULTS

Over-representation of Female, Asian, least deprived and grammar school groups were found in applicant and selected pools compared with the UK population. White ethnic applicants were significantly more selected than Black (OR 0.25), Asian (OR 0.57) and Mixed (OR 0.80) ethnicities, while least deprived applicants were significantly more selected than most deprived (OR 0.59). Grammar school education increased odds of selection by 1.8 when compared to state school. The addition of UCAT to the model for applicants reduced ethnic disparities but led to disparities between other groups.

CONCLUSION

Current widening participation practices focus on attracting applicants from lower socio-economic groups. However, this study showed that ethnicity, sex and educational background biases also affect demographic diversity in dentistry. The UCAT shows promise in levelling the playing field; however, widening access measures will only succeed if selection committees radically change selection processes to address the systemic biases, enabling the dentists of tomorrow to represent the society they serve.

Robust, defensible, and fair: The AMEE guide to selection into medical school: AMEE Guide No. 153

Selection is the first assessment of medical education and training. Medical schools must select from a pool of academically successful applicants and ensure that the way in which they choose future clinicians is robust, defensible, fair to all who apply and cost-effective. However, there is no comprehensive and evidence-informed guide to help those tasked with setting up or rejuvenating their local selection process. To address this gap, our guide draws on the latest research, international case studies and consideration of common dilemmas to provide practical guidance for designing, implementing and evaluating an effective medical school selection system. We draw on a model from the field of instructional design to frame the many different activities involved in doing so: the ADDIE model. ADDIE provides a systematic framework of Analysis (of the outcomes to be achieved by the selection process, and the barriers and facilitators to achieving these), Design (what tools and content are needed so the goals of selection are achieved), Development (what materials and resources are needed and available), Implementation (plan [including piloting], do study and adjust) and Evaluation (quality assurance is embedded throughout but the last step involves extensive evaluation of the entire process and its outcomes).HIGHLIGHTSRobust, defensible and fair selection into medical school is essential. This guide systematically covers the processes required to achieve this, from needs analysis through design, development and implementation, to evaluation of the success of a selection process.

Does medical education reform change who is selected? A national cross-sectional survey from China

OBJECTIVES

Approximately 10 years ago, China introduced an education plan to improve the overall quality of medical education and to better serve the population's health needs. Many medical schools were then recognised and financed by China's Ministry of Education to develop and operationalise new pilot programmes (PPs) aligned with this plan. These ran in parallel with the traditional programmes (TPs). One way to achieve the plan's first aim, improving the quality of medical education, is to select academically stronger candidates. We, thus, examined and compared who were selected into PPs and TPs.

DESIGN

Cross-sectional study.

SETTING

Data were collected from 123 medical schools across China via the 2021 China Medical Student Survey.

PARTICIPANTS

Participants were undergraduate clinical medicine students across all year groups.

PRIMARY AND SECONDARY OUTCOME MEASURES

Medical school selection was via the National College Entrance Examination (NCEE). Medical students' NCEE performance and their sociodemographics were used as the primary and secondary outcome measures. Mann-Whitney or χ2 tests were used to compare the means between educational programmes (PPs vs TPs) and various selection outcomes. Multilevel mixed-effects regressions were employed to account for school idiosyncratic selection results.

RESULTS

Of the 204 817 respondents, 194 163 (94.8%) were in a TP and 10 654 (5.2%) a PP. PP respondents (median=75.2, IQR=69.5-78.8) had significantly higher NCEE scores than their TP counterparts (median=73.9, IQR=68.5-78.7). Holding constant their NCEE score, PP respondents were significantly more likely to come from urban areas, not be first-generation college students, and have parents with higher occupational status and income.

CONCLUSIONS

Assuming quality can be indicated by prior academic achievement at the point of selection, PPs achieved this mission. However, doing so limited medical students' diversity. This may be unhelpful in achieving the Education Plan's goal to better serve China's health needs.

Widening Access: what do dental school websites signal to prospective students?

Introduction Widening Access (WA) policies aim to ensure that a professional workforce reflects the community that it serves by facilitating the admission of applicants from under-represented demographics. WA has not been extensively studied in UK dental education. Website discourses are an important element in students' higher education choices and have the potential to engage those who might be under-represented.Methods Critical discourse analysis was used to investigate contents of the 16 UK dental school webpages in relation to WA, based on a previous study within medical education. Data were contextualised through identification of drivers and levers, as well as warrants of WA.Results Discourses emphasising social mobility, and the resultant advancement within social hierarchy of an individual, dominated the narrative rationalising WA as an initiative. WA was depicted as a mechanism to support applicants of high academic ability and exhibiting commitment to studying dentistry but who were unable to show their true potential due to their underprivileged backgrounds. This presentation portrayed dental schools as generous establishments, selectively granting career-advancement opportunities to disadvantaged students. Discourses on the benefits of WA for patient care and workforce diversification were largely absent.Conclusions Discourses representing WA on websites of UK dental schools are limited and do not portray applicants from deprived backgrounds or under-represented groups as individuals bringing unique positive benefits to dentistry and patient care. We encourage dental schools to consider alternate messages for attracting applicants from under-represented demographics.

"Important but risky": attitudes of global thought leaders towards cost and value research in health professions education

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.

Preparing for selection success: Socio-demographic differences in opportunities and obstacles

INTRODUCTION

There is a growing drive to improve the heterogeneity of medical school cohorts. However, those from lower socio-economic groups remain under-represented. Understanding the methods used by applicants to prepare for medical school selection, and the challenges they face with respect to opportunities and access, may provide important insights to this lack of diversity. This research considered the influence of socio-demographic background on preparation for medical school selection and on the successful offer of a place.

METHODS

All eligible applicants to a large UK medical school were invited to complete an anonymous online survey (international and mature applicants excluded), detailing demographic data and experiences of preparing for selection and challenges faced (n = 1885). Selection outcomes across all UK medical schools were examined for consenting students (n = 955). Univariate and multivariate analyses explored the associations of preparatory activities and demographic data with subsequent offer of a place at a UK medical school.

RESULTS

The survey response rate was 66.4%. Clinical work experience (hospital or general practice), fee-based courses for admissions tests and school preparation courses for interview were activities significantly associated with the offer of a place (P < .05). Those attending independent (private) schools most frequently reported school support and fee-based courses to support preparation (P < .01). Applicants from state non-selective (SNS) schools and lower socio-economic groups more frequently reported challenges in accessing fee-based support, school interview courses and clinical work experience (P ≤ .02).

DISCUSSION

Clinical work experience, commercial courses for admissions tests and school-based support for interview represent areas of preparation that are associated with success. However, they also represent areas that are more challenging to access for demographic groups traditionally under-represented in medicine. Addressing complex issues of fairness in highly selective higher education settings can appear an insurmountable task. These preparatory activities represent key areas for applicants, schools and institutions to explore and address.

Selection for health professions education leads to increased inequality of opportunity and decreased student diversity in The Netherlands, but lottery is no solution: A retrospective multi-cohort study

BACKGROUND

Concerns exist about the role of selection in the lack of diversity in health professions education (HPE). In The Netherlands, the gradual transition from weighted lottery to selection allowed for investigating the variables associated with HPE admission, and whether the representativeness of HPE students has changed.

METHOD

We designed a retrospective multi-cohort study using Statistics Netherlands microdata of all 16-year-olds on 1 October 2008, 2012, and 2015 (age cohorts, N > 600,000) and investigated whether they were eligible students for HPE programs (n > 62,000), had applied (n > 14,000), and were HPE students at age 19 (n > 7500). We used multivariable logistic regression to investigate which background variables were associated with becoming an HPE student.

RESULTS

HPE students with ≥1 healthcare professional (HP) parent, ≥1 top-10% income/wealth parent, and women are overrepresented compared to all age cohorts. During hybrid lottery/selection (cohort-2008), applicants with ≥1 top-10% wealth parent and women had higher odds of admission. During 100% selection (cohort-2015) this remained the case. Additionally, applicants with ≥1 HP parent had higher odds, those with a migration background had lower odds.

CONCLUSIONS

Odds of admission are increasingly influenced by applicants' backgrounds. Targeted recruitment and equitable admissions procedures are required to increase matriculation of underrepresented students.

Insights on selection of undergraduate dental students

INTRODUCTION

The goal of selection to dental education was to find those with the greatest aptitude for dentistry. Recently, schools have introduced a variety of tools; however, these have often been adopted without appropriate evaluation regarding existing evidence for fairness, reliability or validity. We explore dental admissions staff beliefs about the quality of different selection tools, with the objective of exploring their decision-making in implementing selection practices.

METHODS

This qualitative study is underpinned by a social constructionist epistemology, in which our principal concern is "explicating the processes by which people come to describe, explain or otherwise account for the world (including themselves) in which they live." We conducted individual interviews with 15 of the 16 UK dental admission leads to elicit their views around admissions processes and aims. Data coding and analysis were initially inductive, using thematic analysis. After the themes emerged, we applied a deductive framework of affordances to group themes and then examined these for heuristics.

RESULTS AND DISCUSSION

We identified three main themes; "Selection Tool Use," "Widening Participation Practices," and "Professionalising the Admission Lead Role." Admission leads spoke favourably of tools that allowed a "holistic" view of the applicants "potential". Selection tools were favoured if they enabled "Gut feeling". Leads spoke of evaluating candidates, making sure they were "rounded", and "know what dentistry is all about." In justifying the use of elements of their procedure, the use of heuristics was prominent.

CONCLUSION

In order to minimise the potential consequences of poor selection decisions, it is important to acknowledge that dental admission leads are at risk of depending on sub-optimal heuristics to make judgements about effective selection (shaped by previous practices) rather than using more rational decision-making processes based on the extant evidence (regarding the quality of different selection tools). Future research may be usefully informed by the knowledge translation literature to offer solutions for improving selection practices in dental education.

Challenging the deficit discourse in medical schools through reverse mentoring-using discourse analysis to explore staff perceptions of under-represented medical students

INTRODUCTION

Despite the increasing diversity of UK medical students, students from low-socioeconomic backgrounds, some minority groups and members of communities with protected identities remain under-represented in medicine. In trying to ascertain why this under-representation persists, literature focuses on the barriers and challenges faced by under-represented students as opposed to the institution's responsibility to remove or mitigate these obstacles. One UK University created a reverse mentoring scheme enabling students to mentor senior members of the medical faculty to help them understand the perspectives and experiences of students from minority backgrounds. This paper explores whether changes in staff perceptions of under-represented students resulted from engaging with reverse mentoring.

METHODS

This qualitative study explored the impact of the reverse mentoring scheme. Staff mentees were required to write a narrative text about the Higher Education journey of an under-represented medical student before and after the reverse mentoring intervention. These texts were compared using discourse analysis to identify shifts in language use that demonstrated a change in perceptions.

RESULTS

The key themes from five senior staff members indicate a positive change in staff characterisation of the students and an acceptance of institutional responsibility for challenges faced. Initial texts revealed a superficial understanding of the student journey that focused on individual deficit but had fairy tale endings depicting the medical school as benevolent. The follow-up texts revealed a deeper understanding reflected by the portrayal of students as capable agents and containing pragmatic endings acknowledging the responsibility of the medical school.

CONCLUSION

These findings highlight how removed senior staff can be from the reality of the student experience and that engaging with reverse mentoring helps to raise awareness and challenges the students face. This suggests a route for constructive change in medical schools and endorses the benefits of facilitating open discussion around educational inequity.

Widening Participation in Medicine: The Impact of Medical Student-Led Conferences for Year 12 Pupils

PURPOSE

Individuals from lower socio-economic backgrounds are under-represented in the medical profession: confidence is a barrier to them successfully applying to medical school. This study examined the impact of two student-led conferences for Year 12 pupils, at which they had the opportunity to present their work. It looked at the ability of the conferences to improve participant confidence, and the feasibility of its replication by other student-led groups.

METHODS

The first, Conference A, had more time and finances invested into it than the second, Conference B. The latter relied solely on university society funding, but utilised WP criteria for selection of participants. Participants identified their confidence in six areas on a ten-point scale, immediately before and after the intervention.

RESULTS

A paired t-test showed a significant improvement (p < 0.01) in all areas of confidence for both conferences. Cohen's d showed Conference A had larger effect sizes in five out of six areas than Conference B.

CONCLUSION

This intervention has demonstrated a significant positive impact on participant confidence: a key factor to improve their chance of successful admission to medical school. Supporting participants with their presentations prior to the conference was found to further enhance their confidence. The authors feel that this work could be replicated successfully by other student groups.

Opening up the black box of a Gateway to Medicine programme: a realist evaluation

OBJECTIVES

A Gateway to Medicine programme, developed in partnership between a further and higher education setting and implemented to increase the socioeconomic diversity of medicine, was examined to identify precisely what works within the programme and why.

DESIGN

This study employed realist evaluation principles and was undertaken in three phases: document analysis and qualitative focus groups with widening access (WA) programme architects; focus groups and interviews with staff and students; generation of an idea of what works.

SETTING

Participants were recruited from a further/higher education setting and were either enrolled or involved in the delivery of a Gateway to Medicine programme.

PARTICIPANTS

Twelve staff were interviewed either individually (n=3) or in one of three group interviews. Nine focus groups (ranging from 5 to 18 participants in each focus group) were carried out with Gateway students from three consecutive cohorts at 2-3 points in their Gateway programme year.

RESULTS

Data were generated to determine what 'works' in the Gateway programme. Turning a realist lens on the data identified six inter-relating mechanisms which helped students see medicine as attainable and achievable and prepared them for the transition to medical school. These were academic confidence (M1); developing professional identity (M2); financial support/security (M3); supportive relationships with staff (M4) and peers (M5); and establishing a sense of belonging as a university student (M6).

CONCLUSIONS

By unpacking the 'black box' of a Gateway programme through realist evaluation, we have shown that such programmes are not solely about providing knowledge and skills but are rather much more complex in respect to how they work. Further work is needed to further test the mechanisms identified in our study in other contexts for theory development and to identify predictors of effectiveness in terms of students' preparedness to transition.

Redefining scholarship for health professions education: AMEE Guide No. 142

Scholarship is an integral aspect of academia. It shapes the practice of individuals and the field and is often used to inform career progression decisions and policies. This makes it high stakes. Yet it is complex, and ambiguous. Definitions vary and the term does not necessarily translate well across contexts. In this AMEE guide, our aim is to establish a contemporary definition of scholarship which is appropriate to health professions education (HPE). Our specific objectives are to provide guidance to support colleagues in their career development as professional educators and to challenge biases and assumptions about scholarship which may still exist in educational systems and structures. Ultimately, we hope that this work will advance the stature/standing of scholarship in the field. We provide a general definition of scholarship and how this relates to the scholarship of teaching (and learning) (SoT[L]) and scholarly teaching. Drawing on Boyer's seminal work, we describe different types of scholarship and reflect on how these apply to HPE, before moving on to describe different types of engagement with scholarship in HPE, including scope of contribution and influence. Using cases and examples, we illustrate differences in scholarly engagement across stages of a career, contexts, and ways of engaging. We provide guidance on how to assess 'quality' of scholarship. We offer practical advice for health professions' educators seeking academic advancement. We advocate that institutional leaders consider their systems and structures, so that these align with faculty work patterns, and judge teaching and professional practice appropriately. We conclude by offering a new definition of scholarship in HPE.

Meritocratic and fair? The discourse of UK and Australia's widening participation policies

INTRODUCTION

Globally, people with the academic and personal attributes to successfully study medicine experience disadvantages associated with sociodemographic factors. Governments have attempted to address this issue via macrolevel policies aimed at widening participation (WP) to medicine. These policies differ by country, suggesting much can be learned from examining and comparing international policy discourses of WP. Our question was: How are discourses of WP to higher and medical education positioned in the UK and Australia?

METHODS

A systematic search strategy was guided by five a priori themes inspired by United Nations Sustainability Goals (2015). Seventeen policy documents (UK n = 9, Australia n = 8) published between 2008 and 2018 were identified. Analysis involved two over-arching, iterative stages: a document analysis then a Foucauldian critical discourse analysis, the latter with the aim of unveiling the power dynamics at play within policy-related discourses.

RESULTS

Discourses of social mobility and individual responsibility within a meritocracy are still paramount in the UK. In contrast, the dominant discourse in Australia is social accountability in achieving equity and workforce diversity, prioritising affirmative action and community values. Similarities between the two countries in terms of WP policy and policy levers have changed over time, linked to the divergence of internal drivers for societal change. Both nations recognise tensions inherent in striving to achieve both local and global goals, but Australia appears to prioritise community values in working towards 'nation building' whereas in the UK the focus on individuality and meritocracy at times seems at odds with achieving parity for disadvantaged individuals.

DISCUSSION

WP policies and practices are situated and contextual so caution must be taken when extrapolating lessons from one context to another. The history of a country and the nature of marginalisation in that country must be scrutinised when trying to understand what drives WP policy.

"The biggest barrier was my own self": the role of social comparison in non-traditional students' journey to medicine

INTRODUCTION

Social comparisons strongly influence an individual's concept of self, their aspirations and decisions. This study investigates how non-traditional applicants used social comparison to shape their preferences, beliefs and predictions whilst preparing an application for medical school.

METHODS

Semi-structured interviews were conducted with 12 UK medical students from non-traditional backgrounds to explore their process of 'getting ready' for medical school, and the role social comparison played in their experiences. Thematic analysis was used to inductively develop themes in the data, before findings were interpreted through the 'triadic model' of social comparison.

RESULTS

Findings revealed that participants looked to the opinions of those with similar norms and backgrounds to accept their desire to study medicine. They sought the opinions of 'experts' to affirm a belief in their suitability but lacked confidence until success in crucial examinations 'proved', in their own view, that they had the ability to do medicine. Social comparison to peers who were perceived to be less committed to medicine, and to relatable role models, reassured participants that someone from their background could succeed in medicine.

DISCUSSION

Our findings further understanding about 'how' and 'why' exposure to relevant experts, peers and role models can positively influence application to medicine through the lens of social comparison. We recommend widening access initiatives promote and foster various opportunities for social comparison to help counter non-traditional students' feelings of uncertainty about their ability and prospects, and to reorient their focus away from achieving the required grades before preparing the non-academic aspects of their application.

Sociodemographic and educational characteristics of doctors applying for psychiatry training in the UK: secondary analysis of data from the UK Medical Education Database project

Aims and methodWorkforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression. RESULTS: Those most likely to apply were White, privately educated older doctors with below average performance at medical school.Clinical implicationsTo reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.Declaration of interestNone.

Thinking of selection and widening access as complex and wicked problems

OBJECTIVES

'Wicked problems' are complex in nature, have innumerable causes associated with multiple social environments and actors with unpredictable behaviour and outcomes, and are difficult to define or even resolve. This paper considers why and how the frameworks of complexity theory and wicked problems can help medical educators consider selection and widening access (WA) to medicine through fresh eyes to guide future policy and practice. We illustrate how 'wickedity' can frame the key issues in this area, and then address steps that education stakeholders might take to respond to and act on these issues.

METHODS

We used the 10 properties of a wicked problem to frame common issues in the broad field of selection and WA in medicine. We drew heavily on literature from different disciplines, particularly education, and, through debate and reflection, agreed on the applicability of the theory for illuminating and potentially addressing outstanding issues in selection and WA.

RESULTS

Framing medical school selection using the 10 properties of wicked problems is a means of shifting thinking from erroneous 'simple' solutions to thinking more contextually and receptively. The wicked problem framework positions selection as a multi-causal, complex, dynamic, social problem and foregrounds stakeholders' views and context as being highly relevant in medical school selection.

CONCLUSIONS

The wicked problem lens shifts thinking and action from seeking one elusive, objective truth to recognising the complexity of medical school selection, managing uncertainty, questioning and considering 'issues' associated with medical school selection more productively. Although there are criticisms of this framework, labelling medical selection as 'wicked' provides original insights and genuine reframing of the challenges of this important, and high profile, aspect of medical education. Doing so, in turn, opens the door to different responses than would be the case if selection and WA were simple and readily tamed.

2018 Ottawa consensus statement: Selection and recruitment to the healthcare professions

Selection and recruitment into healthcare education and practice is a key area of interest for educators with significant developments in research, policy, and practice in recent years. This updated consensus statement, developed through a multi-stage process, examines future opportunities and challenges in selection and recruitment. There is both a gap in the literature around and a compelling case for further theoretical and empirical literature to underpin the development of overall selection philosophes and policies and their enactment. More consistent evidence has emerged regarding the quality of different selection methods. Approaches to selection are context-dependent, requiring the consideration of an institution's philosophy regarding what they are trying to achieve, the communities it purports to serve, along with the system within which they are used. Diversity and globalization issues continue to be critically important topics. Further research is required to explore differential attainment and explain why there are substantial differences in culturally acceptable ways of approaching diversity and widening access. More sophisticated evaluation approaches using multi-disciplinary theoretical frameworks are required to address the issues. Following a discussion of these areas, 10 recommendations are presented to guide future research and practice and to encourage debate between colleagues across the globe.

Do changing medical admissions practices in the UK impact on who is admitted? An interrupted time series analysis

INTRODUCTION

Medical admissions must balance two potentially competing missions: to select those who will be successful medical students and clinicians and to increase the diversity of the medical school population and workforce. Many countries address this dilemma by reducing the heavy reliance on prior educational attainment, complementing this with other selection tools. However, evidence to what extent this shift in practice has actually widened access is conflicting.

AIM

To examine if changes in medical school selection processes significantly impact on the composition of the student population.

DESIGN AND SETTING

Observational study of medical students from 18 UK 5-year medical programmes who took the UK Clinical Aptitude Test from 2007 to 2014; detailed analysis on four schools.

PRIMARY OUTCOME

Proportion of admissions to medical school for four target groups (lower socioeconomic classes, non-selective schooling, non-white and male).

DATA ANALYSIS

Interrupted time-series framework with segmented regression was used to identify the impact of changes in selection practices in relation to invitation to interview to medical school. Four case study medical schools were used looking at admissions within for the four target groups.

RESULTS

There were no obvious changes in the overall proportion of admissions from each target group over the 8-year period, averaging at 3.3% lower socioeconomic group, 51.5% non-selective school, 30.5% non-white and 43.8% male. Each case study school changed their selection practice in decision making for invite to interview during 2007-2014. Yet, this within-school variation made little difference locally, and changes in admission practices did not lead to any discernible change in the demography of those accepted into medical school.

CONCLUSION

Although our case schools changed their selection procedures, these changes did not lead to any observable differences in their student populations. Increasing the diversity of medical students, and hence the medical profession, may require different, perhaps more radical, approaches to selection.

What are the features of targeted or system-wide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50

BACKGROUND/PURPOSE

There is interest to increase diversity among health professions trainees. This study aims to determine the features/effects of interventions to promote recruitment/admission of under-represented minority (URM) students to health professions programs.

METHODOLOGY

This registered BEME review applied systematic methods to: title/full-text inclusion review, data extraction, and quality assessment (QA). Included studies reported outcomes for interventions designed to increase diversity of health professions education (HPE) programs' recruitment and admissions.

RESULTS

Of 7225 studies identified 86 met inclusion criteria. Interventions addressed: admissions (34%), enrichment (19%), outreach (15%), curriculum (3%), and mixed (29%). They were mostly single center (76%), from the United States (81%), in medicine (45%) or dentistry (22%). URM definition was stated in only 24%. The dimension most commonly considered was ethnicity/race (88%). The majority of studies (81%) found positive effects. Heterogeneity precluded meta-analysis. Qualitative analysis identified key features: admissions studies points systems and altered weightings; enrichment studies highlighted academic, application and exam preparation, and workplace exposure.

DISCUSSION/CONCLUSIONS

Several intervention types may increase diversity. Limited applicant pools were a rate-limiting feature, suggesting efforts earlier in the continuum are needed to broaden applicant pools. There is a need to examine underlying cultural and external pressures that limit programs' acceptance of initiatives to increase diversity.

Testing for medical school selection: What are prospective doctors' experiences and perceptions of the GAMSAT and what are the consequences of testing?

Written tests for selection into medicine have demonstrated reliability and there is accumulating evidence regarding their validity, but we know little about the broader impacts or consequences of medical school selection tests from the perspectives of key stakeholders. In this first Australian study of its kind, we use consequential validity as a theoretical lens to examine how medical school students and applicants view and experience the Graduate Medical Schools Admission Test (GAMSAT), and the consequences of testing. Participants (n = 447) were recruited from five graduate-entry medical schools across Australia and a publicly available online test preparation forum. An online survey was used to gather demographic information, and quantitative and qualitative data. Quantitative data were analysed via descriptive statistics and qualitative data were thematically analysed. The findings showed there was a considerable financial burden associated with preparing for and sitting the GAMSAT and moderate agreement regarding the GAMSAT as a fair selection method. The main unintended consequences of using the GAMSAT as a selection tool included barriers related to test affordability and language, and socialisation into the hidden curriculum of medicine. Selection tools such as the GAMSAT have some limitations when the goals are to support equitable participation in medicine and professional identity development. Our study highlights the value interpretive and theoretically-informed research in contributing to the evidence base on medical school selection.

"Aspirations of people who come from state education are different": how language reflects social exclusion in medical education

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.

The Medical School Admissions Process and Meeting the Public's Health Care Needs: Never the Twain Shall Meet?

Medical schools typically assess how good their selection process is using metrics such as students' assessment performance and the success of alumni on later indicators of academic ability and clinical competence, such as Royal College of Physicians or specialty board examinations. Addressing global issues with the maldistribution of doctors and increasing numbers of new medical school graduates choosing not to work in a clinical context requires different measurements of medical school admissions processes, like those related to graduates' career outcomes (e.g., working in underserved regions and/or working in certain specialties). This shift in focus is not straightforward. Medical education is a complex social system where, intentionally or not, medical schools focus on reproducing cultural, historical, and social norms. Simple solutions are often proposed, but they are insufficient to address these complex drivers. Instead, it is time to step back and think very differently about medical school admissions. In this Invited Commentary, the author proposes new solutions to address these issues, including bringing into the medical school selection process the perspectives of other key stakeholders; increasing collaboration and dialogue across these stakeholder groups; changing the performance metrics by which medical schools are assessed in the global education marketplace; and developing and evaluating new selection processes and tools. Medical schools must engage more reflectively and collaboratively in debates about how to align medical school admissions and meeting the health care needs of the public.

Widening interest, widening participation: factors influencing school students' aspirations to study medicine

BACKGROUND

Under-representation of some socio-economic groups in medicine is rooted in under-representation of those groups in applications to medical school. This study aimed to explore what may deter school-age children from applying to study medicine.

METHODS

Workshops were undertaken with school students aged 16-17 years ('Year 12', n = 122 across three workshops) and 13-14 years ('Year 9', n = 295 across three workshops). Workshops used a variety of methods to identify and discuss participants' perceptions of medicine, medical school and the application process. Year 12 workshops focused on applications and medical school, while Year 9 took a broader approach reflecting their relative distance from applying. Subsequent workshops were informed by the findings of earlier ones.

RESULTS

The main finding was that potential applicants had limited knowledge about medicine and medical school in several areas. Older students would benefit from accessible information about medical degrees and application processes, access to work experience opportunities and personal contact with medical students and junior doctors, particularly those from a similar background. Younger students demonstrated a lack of awareness of the breadth of medical careers and a limited understanding of what medicine encompasses. Many Year 9 students were attracted by elements of practice which they did not associate with medicine, such as 'talking to people with mental health problems'. An exercise addressing this elicited an increase in their interest in medicine. These issues were identified by participants as being more marked for those without knowledgeable support at home or school. It was apparent that school teachers may not be equipped to fill these knowledge gaps.

CONCLUSION

Gaps in knowledge and support may reflect the importance of 'social capital' in facilitating access to medical school. Medical schools could act as hubs to introduce students to resources which are essential for widening participation. Outreach and support to schools may ensure that fundamental knowledge gaps are equitably addressed for all prospective applicants. More generally, a focus on medicine which under-emphasises aspects of medical practice involving communication may deter some students and have longer term impact on recruitment to careers including general practice and psychiatry.

Matching the production of doctors with national needs

CONTEXT

Matching the supply of health workers to need is necessary if a health system is to be sustainable, affordable and fit for purpose. On the 30th anniversary of the 1988 Edinburgh Declaration of the World Federation for Medical Education, levels of compliance with the 10th recommendation, 'Ensure admission policies that match the numbers of students trained with national needs for doctors', warrant review. There are two domains to such a review, concerning, respectively, how well these health needs are known, and whether workforce supply is well matched.

METHODS

This is a literature review-based analysis of extant health system planning, which underpins current understanding of national health needs and of the consequent alignment of student selection processes.

RESULTS

The core finding is that national need for doctors, and any other health workers, is not confidently known for any jurisdiction. Consequently, validation of student selection processes is impossible against this endpoint and data to validate these processes against the alternative endpoint of a positive impact on health outcomes do not exist. Data do exist to suggest some student selection processes result in desirable career and career location uptakes.

Factors associated with junior doctors' decisions to apply for general practice training programmes in the UK: secondary analysis of data from the UKMED project

BACKGROUND

The UK, like many high-income countries, is experiencing a worsening shortfall of general practitioners (GPs) alongside an increasing demand for their services. At the same time, factors influencing junior doctors' decisions to apply for GP training are only partially understood and research in this area has been hampered by the difficulties in connecting the datasets that map the journey from student to qualified GP. The UK Medical Education Database (UKMED) has been established to ameliorate this problem by linking institutional data across the spectrum of medical education from school to specialty training. Our study aimed to use UKMED to investigate which demographic and educational factors are associated with junior doctors' decisions to apply for GP training.

METHODS

Study data, provided by the UKMED Development Group and accessed remotely, contained longitudinal educational and sociodemographic information on all doctors who entered UK medical schools in the 2007/2008 academic year and who made first-time specialty training applications in 2015. We used multivariable logistic regression models to investigate two binary outcomes, namely (1) application to GP training, possibly alongside applications to other specialties, and (2) application solely to GP training.

RESULTS

Of 7634 doctors in the sample, 43% applied to GP training possibly alongside other specialities and 26% applied solely to GP training. The odds of applying to GP training were associated with particular demographic factors (being female, non-white or secondary educated in the UK increased the odds of application) and educational factors (non-graduate entry, intercalation and above-median academic performance during medical school all decreased the odds of application). After adjusting for these factors, both the medical school and the foundation school attended were independently associated with the odds of applying to GP training.

CONCLUSIONS

Our findings suggest that the supply and demand imbalance in UK primary care might be improved by (1) efforts to attract greater numbers of female, non-white and UK secondary-educated students into medical schools, and (2) targeting resources at medical and foundation schools that deliver doctors likely to fill significant gaps in the workforce. Further research is required to better understand inter-school differences and to develop strategies to improve recruitment of GP trainees.

Examining the predictors of academic outcomes for indigenous Māori, Pacific and rural students admitted into medicine via two equity pathways: a retrospective observational study at the University of Auckland, Aotearoa New Zealand

OBJECTIVE

To determine associations between admission markers of socioeconomic status, transitioning, bridging programme attendance and prior academic preparation on academic outcomes for indigenous Māori, Pacific and rural students admitted into medicine under access pathways designed to widen participation. Findings were compared with students admitted via the general (usual) admission pathway.

DESIGN

Retrospective observational study using secondary data.

SETTING

 6-year medical programme (MBChB), University of Auckland, Aotearoa New Zealand. Students are selected and admitted into Year 2 following a first year (undergraduate) or prior degree (graduate).

PARTICIPANTS

1676 domestic students admitted into Year 2 between 2002 and 2012 via three pathways: GENERAL admission (1167), Māori and Pacific Admission Scheme-MAPAS (317) or Rural Origin Medical Preferential Entry-ROMPE (192). Of these, 1082 students completed the programme in the study period.

MAIN OUTCOME MEASURES

Graduated from medical programme (yes/no), academic scores in Years 2-3 (Grade Point Average (GPA), scored 0-9).

RESULTS

735/778 (95%) of GENERAL, 111/121 (92%) of ROMPE and 146/183 (80%) of MAPAS students graduated from intended programme. The graduation rate was significantly lower in the MAPAS students (p<0.0001). The average Year 2-3 GPA was 6.35 (SD 1.52) for GENERAL, which was higher than 5.82 (SD 1.65, p=0.0013) for ROMPE and 4.33 (SD 1.56, p<0.0001) for MAPAS. Multiple regression analyses identified three key predictors of better academic outcomes: bridging programme attendance, admission as an undergraduate and admission GPA/Grade Point Equivalent (GPE). Attending local urban schools and higher school deciles were also associated with a greater likelihood of graduation. All regression models have controlled for predefined baseline confounders (gender, age and year of admission).

CONCLUSIONS

There were varied associations between admission variables and academic outcomes across the three admission pathways. Equity-targeted admission programmes inclusive of variations in academic threshold for entry may support a widening participation agenda, however, additional academic and pastoral supports are recommended.

'Why not you?' Discourses of widening access on UK medical school websites

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.

The qualitative orientation in medical education research

Qualitative research is very important in educational research as it addresses the "how" and "why" research questions and enables deeper understanding of experiences, phenomena and context. Qualitative research allows you to ask questions that cannot be easily put into numbers to understand human experience. Getting at the everyday realities of some social phenomenon and studying important questions as they are really practiced helps extend knowledge and understanding. To do so, you need to understand the philosophical stance of qualitative research and work from this to develop the research question, study design, data collection methods and data analysis. In this article, I provide an overview of the assumptions underlying qualitative research and the role of the researcher in the qualitative process. I then go on to discuss the type of research objectives which are common in qualitative research, then introduce the main qualitative designs, data collection tools, and finally the basics of qualitative analysis. I introduce the criteria by which you can judge the quality of qualitative research. Many classic references are cited in this article, and I urge you to seek out some of these further reading to inform your qualitative research program.

Selecting for a sustainable workforce to meet the future healthcare needs of rural communities in Australia

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.

Who do you think you are? Medical student socioeconomic status and intention to work in underserved areas

A frequently cited rationale for increasing the participation of students from low socioeconomic status (SES) backgrounds is that it will create a workforce who will choose to work in low SES and medically underserviced communities. Two theoretical arguments, one that supports and one that contradicts this assumption, are proposed to explain the practice location intentions of medical students which we examine in a longitudinal analysis. SES background and future intentions of 351 applicants to an undergraduate medical degree were assessed at Time 1, with intentions re-assessed one year later for 96% of those who were enrolled as medical students. Students from very low (and very high) SES backgrounds indicated lower intention to practice in low SES or medically underserviced areas than those from mid-range SES backgrounds. Males and students from non-English speaking backgrounds indicated less desire to work in low SES areas, perhaps explained by high aspirational motivation. SES accounted for a relatively small amount of variance in practice intentions. Alternate predictors of practice location, including individual values and training effects, and their implications for selection practice, are discussed.

Let us not neglect the impact of organizational culture on increasing diversity within medical schools

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Facilitating admissions of diverse students: A six-point, evidence-informed framework for pipeline and program development

INTRODUCTION

Several national level calls have encouraged reconsideration of diversity issues in medical education. Particular interest has been placed on admissions, as decisions made here shape the nature of the future physician workforce. Critical analysis of current practices paired with evidence-informed policies may counter some of the barriers impeding access for underrepresented groups.

METHODS

We present a framework for diversity-related program development and evaluation grounded within a knowledge translation framework, and supported by the initiation of longitudinal collection of diversity-related data. We provide an illustrative case study for each component of the framework. Descriptive analyses are presented of pre/post intervention diversity metrics if applicable and available.

RESULTS

The framework's focal points are: 1) data-driven identification of underrepresented groups, 2) pipeline development and targeted recruitment, 3) ensuring an inclusive process, 4) ensuring inclusive assessment, 5) ensuring inclusive selection, and 6) iterative use of diversity-related data. Case studies ranged from wording changes on admissions websites to the establishment of educational and administrative offices addressing needs of underrepresented populations.

CONCLUSIONS

We propose that diversity-related data must be collected on a variety of markers, developed in partnership with stakeholders who are most likely to facilitate implementation of best practices and new policies. These data can facilitate the design, implementation, and evaluation of evidence-informed diversity initiatives and provide a structure for continued investigation into 'interventions' supporting diversity-related initiatives.

Widening access in selection using situational judgement tests: evidence from the UKCAT

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.

Curriculum reform: the more things change, the more they stay the same?

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What do UK doctors in training value in a post? A discrete choice experiment

CONTEXT

Many individual and job-related factors are known to influence medical careers decision making. Medical trainees' (residents) views of which characteristics of a training post are important to them have been extensively studied but how they trade-off these characteristics is under-researched. Such information is crucial for the development of effective policies to enhance recruitment and retention. Our aim was to investigate the strength of UK foundation doctors' and trainees' preferences for training post characteristics in terms of monetary value.

METHODS

We used an online questionnaire study incorporating a discrete choice experiment (DCE), distributed to foundation programme doctors and doctors in training across all specialty groups within three UK regions, in August-October 2013. The main outcome measures were monetary values for training-post characteristics, based on willingness to forgo and willingness to accept extra income for a change in each job characteristic, calculated from regression coefficients.

RESULTS

The questionnaire was answered by 1323 trainees. Good working conditions were the most influential characteristics of a training position. Trainee doctors would need to be compensated by an additional 49.8% above the average earnings within their specialty to move from a post with good working conditions to one with poor working conditions. A training post with limited rather than good opportunities for one's spouse or partner would require compensation of 38.4% above the average earnings within their specialty. Trainees would require compensation of 30.8% above the average earnings within their specialty to move from a desirable to a less desirable locality. These preferences varied only to a limited extent according to individual characteristics.

DISCUSSION

Trainees place most value on good working conditions, good opportunities for their partners and desirable geographical location when making career-related decisions. This intelligence can be used to develop alternative models of workforce planning or to develop information about job opportunities that address trainees' values.