Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work

When the Penny Drops: Understanding how social class influences speciality careers in the UK medical profession

In the UK, the medical profession is socially exclusive and socially stratified as doctors from more advantaged backgrounds are more likely to train for specialities with more competitive entry. However, in research to date the causes and consequences of social stratification have been overlooked. We explore this subject here, drawing on a qualitative study comprising in-depth interviews with 30 medical students and doctors from less advantaged socio-economic backgrounds negotiating medical school and early careers. Using Bourdieu's 'theory of practice' we show how socialisation in the family and at school influences how aspirant medics from less advantaged backgrounds view the world, suggesting some inclination towards more community orientated careers, which may be less competitive. However, these tendencies are encouraged as they lack stocks of social, economic and cultural capital, which are convertible to power and position in the field. While allowing for both choice and constraint our core argument is that speciality outcomes are sometimes inequitable and potentially inefficient, as doctors from more advantaged backgrounds have privileged access to more competitive careers for reasons not solely related to ability or skill. Our main theoretical contribution is to literature in the sociology of medical education where ours is the first study to open-up the 'black box' of causal factors connecting medical students' resources on entering the field of education and training with speciality outcomes, though our findings also have important implications for practitioners, the profession and for patients. We discuss the implications for safe and effective healthcare and how this informs directions for future research.

How do the post-graduation outcomes of students from gateway courses compare to those from standard entry medicine courses at the same medical schools?

BACKGROUND

Widening participation (WP) for underrepresented students through six-year gateway courses helps to widen the demographic representation of doctors in the UK. 'Most students from gateway courses graduate, even though many enter with lower grades than standard entry medicine students.' This study aims to compare the graduate outcomes of gateway and SEM cohorts from the same universities.

METHODS

Data from 2007-13 from the UK Medical Education Database (UKMED) were available for graduates of gateway and SEM courses at three UK medical schools. Outcome measures were passing an entry exam on the first attempt, Annual Review of Competency Progression (ARCP) outcome and being offered a level one training position from the first application. The univariate analysis compared the two groups. Logistic regressions, predicting outcomes by course type, controlled for attainment on completion of medical school.

RESULTS

Four thousand four hundred forty-five doctors were included in the analysis. There was no difference found in the ARCP outcome between gateway and SEM graduates. Gateway graduates were less likely to pass their first attempt at any membership exam than graduates of SEM courses (39% vs 63%). Gateway graduates were less likely to be offered a level 1 training position on their first application (75% vs 82%). Graduates of gateway courses were more likely to apply to General Practitioner (GP) training programmes than SEM graduates (56% vs 39%).

CONCLUSIONS

Gateway courses increase the diversity of backgrounds represented within the profession and importantly the number of applications to GP training. However, differences in cohort performance are shown to continue to exist in the postgraduate arena and further research is required to ascertain the reasons for this.

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.

Does performance at the intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination vary according to UK medical school and course type? A retrospective cohort study

OBJECTIVES

The knowledge, skills and behaviours required of new UK medical graduates are the same but how these are achieved differs given medical schools vary in their mission, curricula and pedagogy. Medical school differences seem to influence performance on postgraduate assessments. To date, the relationship between medical schools, course types and performance at the Membership of the Royal Colleges of Surgeons examination (MRCS) has not been investigated. Understanding this relationship is vital to achieving alignment across undergraduate and postgraduate training, learning and assessment values.

DESIGN AND PARTICIPANTS

A retrospective longitudinal cohort study of UK medical graduates who attempted MRCS Part A (n=9730) and MRCS Part B (n=4645) between 2007 and 2017, using individual-level linked sociodemographic and prior academic attainment data from the UK Medical Education Database.

METHODS

We studied MRCS performance across all UK medical schools and examined relationships between potential predictors and MRCS performance using χ2 analysis. Multivariate logistic regression models identified independent predictors of MRCS success at first attempt.

RESULTS

MRCS pass rates differed significantly between individual medical schools (p<0.001) but not after adjusting for prior A-Level performance. Candidates from courses other than those described as problem-based learning (PBL) were 53% more likely to pass MRCS Part A (OR 1.53 (95% CI 1.25 to 1.87) and 54% more likely to pass Part B (OR 1.54 (1.05 to 2.25)) at first attempt after adjusting for prior academic performance. Attending a Standard-Entry 5-year medicine programme, having no prior degree and attending a Russell Group university were independent predictors of MRCS success in regression models (p<0.05).

CONCLUSIONS

There are significant differences in MRCS performance between medical schools. However, this variation is largely due to individual factors such as academic ability, rather than medical school factors. This study also highlights group level attainment differences that warrant further investigation to ensure equity within medical training.

Factors associated with the rural and remote practice of medical workforce in Maluku Islands of Indonesia: a cross-sectional study

BACKGROUND

Many factors contribute to engagement in rural and remote (RR) medical practice, but little is known about the factors associated with rural and remote medical practice in such remote locations as the Maluku Province of Indonesia. This study describes factors associated with actual RR practice, preferred RR practice, and intention to remain practice in Maluku Province.

METHODS

An online survey of work-related experience and intentions for future rural work was administered to 410 doctors working in the Maluku province of Indonesia. Participant characteristics were described using descriptive statistics, associations between the independent variables with the location of the workforce, intention to remain practice in Maluku, preference for future RR practice in Maluku were analysed using Chi-square tests and logistic regression.

RESULTS

A total of 324 responses (79% response rate) were recorded, comprising 70% females and 30% Pattimura University graduates of doctors employed in Maluku. Doctors working in RR areas were more likely to be a GP (OR 3.49, CI 1.03-11.8), have a monthly salary of more than IDR 6 million (OR 11.5, CI 4.24-31.1), and have no additional practice (OR 2.78, CI 1.34-5.78). Doctors intended to stay practice in Maluku were more likely to be born in Maluku (OR 7.77, CI 3.42-17.7) and have graduated from Pattimura University (OR 3.06, CI 1.09-8.54), and less likely to be a temporary employee (OR 0.24, CI 0.10-0.57). Doctors who prefer future RR practice in Maluku were more likely to experience rural living (OR 2.05 CI 1.05-3.99), have a positive indication of the impact of community exposure during medical schools on their current practice (OR 2.08, CI 1.06-4.09), currently practising in RR Maluku (OR 8.23, CI 3.27-20.8); and less likely to have bigger take-home pay (OR 0.30, CI 0.13-0.70).

CONCLUSION

This study indicates that special attention should be given to recruiting doctors with a rural background and ongoing support through attractive opportunities to build a sustainable RR workforce. Since a regional medical school helps supply doctors to the RR areas in its region, a sustained collaboration between medical schools and local government implementing relevant strategies are needed to widen participation and improve the recruitment and retention of RR doctors.

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.

Which disadvantaged students study medicine? Analysis of an English outreach scheme

BACKGROUND

Students from disadvantaged backgrounds continue to be underrepresented in medical education. Widening participation (WP) or outreach schemes seek to increase diversity. Drawing on previously unexplored data from a scheme called Realising Opportunities in England, this study aimed to investigate which high-achieving socioeconomically disadvantaged students in a national WP scheme went on to study medicine at university.

METHODS

This retrospective longitudinal study analyzed data of 2665 16-year-olds on a WP scheme in England between 2010 and 2014. Descriptive statistics and logistic regression analyses investigated any differences between those that went on to study medicine and those that did not. Eligibility for studying medicine, student's neighborhood, gender, ethnicity, parent's higher education experience, exam attainment, interest in medicine, and their subject of choice for university at age 16 were considered.

RESULTS

Of the 1850 students who were tracked to a university destination, only 55 (3%) studied medicine. Participants with high exam results, female, Asian, and from neighborhoods of higher university entry were most likely to study medicine. In the multivariate model, only prior attainment and intention to study medicine predicted studying medicine. Three hundred and forty Realising Opportunities participants expressed interest in studying medicine at age 16, but 80 (24%) were found to have unrealistic aspirations based on their prior academic attainment.

CONCLUSIONS

Attainment and intention were key factors for predicting medicine enrolment among these outreach scheme participants. Some students interested in studying medicine had insufficient academic attainment to compete for medical school places. Efforts to equalize attainment and provide guidance for career choice are crucial factors for students from disadvantaged backgrounds.

Urban or Rural GP? In the Czech Republic It Is not just Distances That Matter

This article proposes a combined mixed methods approach to categorising GP practices. It looks not only at location but also at differences in the nature of the work that rural GPs perform. A data analysis was conducted of the largest health insurance company in the Czech Republic (5.9 million patients, 60% of the population, 100% coverage within the Czech Republic). We performed two data analyses, one for 2014-2015 and one for 2016, and divided GP practices into urban, intermediate, and rural groups (taking into account the OECD methodology). We compared groups in terms of the total annual cost in CZK per adult registered insurance holders. The total volume of data indicated the financial costs of €1.52 billion and €2.57 billion respectively. Both analysis showed differences between all groups of practises which confirmed the assumption that the work of the GP is influenced by regionality. A multidisciplinary hospital is the main factor that fundamentally affects the way a GP's work in that area. The proposed principle of categorising general practices combines geographical and cost characteristics. This requires knowledge of the cost data of healthcare payer and on the basic demographic knowledge of the area. We suggest this principe may be transferrable and particularly suitable for categorising general practice.

The inverse care law re-examined: a global perspective

An inverse care law persists in almost all low-income and middle-income countries, whereby socially disadvantaged people receive less, and lower-quality, health care despite having greater need. By contrast, a disproportionate care law persists in high-income countries, whereby socially disadvantaged people receive more health care, but of worse quality and insufficient quantity to meet their additional needs. Both laws are caused not only by financial barriers and fragmented health insurance systems but also by social inequalities in care seeking and co-investment as well as the costs and benefits of health care. Investing in more integrated universal health coverage and stronger primary care, delivered in proportion to need, can improve population health and reduce health inequality. However, trade-offs sometimes exist between health policy objectives. Health-care technologies, policies, and resourcing should be subjected to distributional analysis of their equity impacts, to ensure the objective of reducing health inequalities is kept in sight.

Why do doctors work in rural areas in high-income countries? A qualitative systematic review of recruitment and retention

OBJECTIVE

To identify and assess the drivers and barriers to recruiting and retaining doctors in rural communities of high-income countries.

DESIGN

A systematic review and thematic analysis.

SETTING

Publications were sourced from medical and scientific databases online.

PARTICIPANTS

Qualitative, mixed-methods and review studies from peer-reviewed journals published since 2000 that discussed recruitment or retention of doctors to rural areas in high-income countries.

MAIN OUTCOME MEASURES

Identification and assessment of themes in the literature pertaining to recruitment and retention of rural doctors. Recurrent themes were assessed for relevance and applicability to current rural shortages.

RESULTS

A thematic analysis was completed on 41 papers assessed as in scope of the review. Papers were scrutinised for relevance to established rural recruitment and retention strategies. Key themes were rural background, education and training, personal and professional circumstances, and integration with the community.

CONCLUSION

While rural origin has long been promoted as the key factor for recruiting rural doctors, initiatives targeting only these individuals ignore a potentially larger cohort of future rural doctors. Rurally focused medical education and training need to encompass students and doctors from all backgrounds. The major barriers to rural recruitment are family-unit considerations for partners and children, concerns over isolation and a poor perception of rural practice. Attracting doctors to practise rurally is only half the challenge however, and strategies to retain rural doctors need a greater focus on personal and professional support networks and community integration. Additional strategies are needed to retain international and bonded doctors restricted to rural areas.

Human resources for health interventions in high- and middle-income countries: findings of an evidence review

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening.

Demographic and socioeconomic characteristics of Canadian medical students: a cross-sectional study

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.

Embarking on a professional career: social advantage in dentistry and medicine. UK dental and medical student applications and admissions, 1996-2011

Objectives The objectives of this research were to compare trends in applications and admissions to dentistry and medicine by sociodemographic status, country/region, academic experience and attainment, for UK domiciled students, and also to compare the odds of gaining admission to each course.Methods Secondary analysis of student data from University and College Admissions Services (UCAS) for focused, successful, UK domiciled applicants whose preferred subject was medicine or dentistry from 1996-2011. Trends for both programmes were examined using univariate and multivariate analysis including logistic regression, both with and without tariff scores.Results Admission ratios to dentistry and medicine are similar, fluctuating over this period. These professions attracted more applications from females, people of Asian ethnicity, direct entrants to university, pupils from selective schools and Londoners. Males, students of White and Black ethnicity, those from England (excluding London), and from lower social groups, were under-represented. The odds of applicants gaining admission were lowest if male, mature (>20 years), of Black ethnicity, from a lower socioeconomic classification, or domiciled in England. When tariff was included in the model, the odds of acceptance for dentistry and medicine were higher for applicants achieving high tariff scores.Discussion This analysis highlights geographic disparities and demonstrates how certain groups remained under-represented, with social inequalities clearly reflected in admissions. The complexity of the societal challenge in accessing these courses must not be underestimated. Social status, geographic region and selective schools remain important determinants of entry, emphasising the importance of educational reform.

Twelve Tips for Applicants from a Disadvantaged Background Considering a Career in Medicine

This article was migrated. The article was marked as recommended. A minority of medical school entrants draw from disadvantaged backgrounds, which remain significantly under-represented within the medical workforce. Whilst multifactorial, this may in part relate to relative lack of information about the admissions process amongst these groups. In this article, Mohammed Abdul Waduud and colleagues offer their twelve essential tips to support students from disadvantaged backgrounds who are considering applying to medical school. The authors, all of whom are from disadvantaged backgrounds, have experience in applying to medical schools within the United Kingdom. The tips within this article should support students from disadvantaged backgrounds to decide whether a career in medicine is right for them and succeed in their applications to study medicine.

Bridging the cultural divide? Exploring school pupils' perceptions of medicine

CONTEXT

Literature published around a decade ago demonstrated that UK individuals from non-traditional groups may not consider, or aspire to, medicine because of sociocultural barriers and instead may perceive medicine as 'not for the likes of me'. Since this time, the UK higher education landscape has undergone significant change, with an increased emphasis on student choice and widening access (WA) initiatives. Consequently, the present study looks anew at the perceptions of medicine held by school pupils from non-traditional backgrounds to assess whether sociocultural factors remain a major barrier to medicine.

METHODS

Focus groups were conducted with 71 high-achieving school pupils in their penultimate or final years (aged 16-18 years). Participants attended UK state-funded schools engaged with medical school WA initiatives. Transcripts were analysed thematically using a data-driven approach. Themes were then interpreted through the conceptual lens of the 'reflexive habitus', an adapted version of Bourdieu's classic concept.

RESULTS

Participants did not perceive that sociocultural differences would deter them from aspiring to, or pursuing, the career of their choice. Some participants identified their 'different' background as a strength to bring to medicine. They reported that intrinsic motivators (personal interest and fulfilment) were most important in their own career choices. When asked what they believed might have motivated current medical students for the career, participants debated the role of extrinsic motivators (high status and income) versus intrinsic ones. 'Hot knowledge' (social contacts) from within medicine helped some participants reconcile any clash in perceived values and better imagine themselves in the profession.

CONCLUSIONS

These non-traditional school pupils from schools engaged with WA initiatives appear to have embraced the belief that medicine is for anyone with the appropriate desire and ability, regardless of background. Furthermore, some pupils reported that some aspects of their 'difference' (diversity) could help enrich the workforce and patient care.

Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study

OBJECTIVES

Many countries are driving forward policies to widen the socioeconomic profile of medical students and to train more medical students for certain specialties. However, little is known about how socioeconomic origin relates to specialty choice. Nor is there a good understanding of the relationship between academic performance and specialty choice. To address these gaps, our aim was to identify the relationship between socioeconomic background, academic performance and accepted offers into specialty training.

DESIGN

Longitudinal, cohort study using data from the UK Medical Education Database (https://www.ukmed.ac.uk/).

PARTICIPANTS

6065 (60% females) UK doctors who accepted offers to a specialty training (residency) post after completing the 2-year generic foundation programme (UK Foundation Programme) between 2012 and 2014.

MAIN OUTCOME MEASURES

Χ² tests were used to examine the relationships between sociodemographic characteristics, academic ability and the dependent variable, specialty choice. Multiple data imputation was used to address the issue of missing data. Multinomial regression was employed to test the independent variables in predicting the likelihood of choosing a given specialty.

RESULTS

Participants pursuing careers in more competitive specialties had significantly higher academic scores than colleagues pursuing less competitive ones. After controlling for the presence of multiple factors, trainees who came from families where no parent was educated to a degree level had statistically significant lower odds of choosing careers in medical specialties relative to general practice (OR=0.78, 95% CI, 0.67 to 0.92). Students who entered medical school as school leavers, compared with mature students, had odds 1.2 times higher (95% CI, 1.04 to 1.56) of choosing surgical specialties than general practice.

CONCLUSIONS

The data indicate a direct association between trainees' sociodemographic characteristics, academic ability and career choices. The findings can be used by medical school, training boards and workforce planners to inform recruitment and retention strategies.

"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.

Relationship between sociodemographic factors and selection into UK postgraduate medical training programmes: a national cohort study

INTRODUCTION

Knowledge about allocation of doctors into postgraduate training programmes is essential in terms of workforce planning, transparency and equity issues. However, this is a rarely examined topic. To address this gap in the literature, the current study examines the relationships between applicants' sociodemographic characteristics and outcomes on the UK Foundation Training selection process.

METHODS

A longitudinal, cohort study of trainees who applied for the first stage of UK postgraduate medical training in 2013-2014. We used UK Medical Education Database (UKMED) to access linked data from different sources, including medical school admissions, assessments and postgraduate training. Multivariable ordinal regression analyses were used to predict the odds of applicants being allocated to their preferred foundation schools.

RESULTS

Applicants allocated to their first-choice foundation school scored on average a quarter of an SD above the average of all applicants in the sample. After adjusting for Foundation Training application score, no statistically significant effects were observed for gender, socioeconomic status (as determined by income support) or whether applicants entered medical school as graduates or not. Ethnicity and place of medical qualification were strong predictors of allocation to preferred foundation school. Applicants who graduated from medical schools in Wales, Scotland and Northern Ireland were 1.17 times, 3.33 times and 12.64 times (respectively), the odds of applicants who graduated from a medical school in England to be allocated to a foundation school of their choice.

CONCLUSIONS

The data provide supportive evidence for the fairness of the allocation process but highlight some interesting findings relating to 'push-pull' factors in medical careers decision-making. These findings should be considered when designing postgraduate training policy.

Rationales for expanding minority physician representation in the workforce: a scoping review

OBJECTIVES

The purpose of this study was to conduct a scoping review of the literature and to categorically map a 15-year trajectory of US undergraduate medical education rationales for and approaches to expanding under-represented minority (URM) physician representation in the medical workforce. Further aims were to comparatively examine related justifications and to consider international implications.

METHODS

From 1 June to 31 July 2015, the authors searched the Cochrane Library, ERIC, PsycINFO, PubMed, Scopus, Web of Science and Google Scholar for articles published between 2000 and 2015 reporting rationales for and approaches to increasing the numbers of members of URMs in undergraduate medical school.

RESULTS

A total of 137 articles were included in the scoping review. Of these, 114 (83%) mentioned workforce diversity and 73 (53%) mentioned concordance. The patient-physician relationship (n = 52, 38%) and service commitment (n = 52, 38%) were the most commonly cited rationales. The most frequently mentioned approaches to increasing minority representation were pipeline programmes (n = 59, 43%), changes in affirmative action laws (n = 32, 23%) and changes in admission policies (n = 29, 21%).

CONCLUSIONS

This scoping review of the 2000-2015 literature on strategies for and approaches to expanding URM representation in medicine reveals a repetitive, amplifying message of URM physician service commitment to vulnerable populations in medically underserved communities. Such message repetition reinforces policies and practices that might limit the full scope of URM practice, research and leadership opportunities in medicine. Cross-nationally, service commitment and patient-physician concordance benefits admittedly respond to recognised societal need, yet there is an associated risk for instrumentally singling out members of URMs to fulfil that need. The proceedings of a 2001 US Institute of Medicine symposium warned against creating a deterministic expectation that URM physicians provide care to minority populations. Our findings suggest that the expanding emphasis on URM service commitment and patient-physician concordance benefits warrants ongoing scrutiny and, more broadly, represent a cautionary tale of unintended consequences for medical educators globally.

Widening participation to medicine: a student-led workshop for medical school applicants

This article was migrated. The article was marked as recommended. Context Widening participation to medicine aims to remove barriers to medical education for under-represented groups. This study examined the impact of a widening participation workshop for medical school applicants. The intervention was delivered by a team of medical student volunteers operating in the North West of England: Manchester Outreach Medics. Methods 39 pupils, typically aged 16-17, attended the workshop at Royal Blackburn Hospital, Lancashire. Activities included a variety of lectures and interactive group sessions. Using questionnaires, participants highlighted their understanding in areas relating to the medical school application process on a scale of zero to ten. This was performed before and after the intervention to allow for comparison. The results were evaluated using a one-tailed paired t-test and Cohen's d effect size. Results There was a significant improvement ( p <0.001, Cohen's d >0.8) in the understanding of all topics assessed. The largest improvements were seen in topics that the participants had little understanding in prior to attending the workshop. Conclusions This student-led activity improved participant understanding in areas pertaining to the medical school application process. The study also showed the effectiveness of pre- and post-intervention questionnaires, which could be used by all post-16 medical widening participation activities in the UK.

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.

Free text adversity statements as part of a contextualised admissions process: a qualitative analysis

BACKGROUND

Medical schools globally are encouraged to widen access and participation for students from less privileged backgrounds. Many strategies have been implemented to address this inequality, but much still needs to be done to ensure fair access for all. In the literature, adverse circumstances include financial issues, poor educational experience and lack of professional-status parents. In order to take account of adverse circumstances faced by applicants, The University of Dundee School of Medicine offers applicants the opportunity to report circumstances which may have resulted in disadvantage. Applicants do this by completing a free text statement, known as an 'adversity statement', in addition to the other application information. This study analysed adversity statements submitted by applicants during two admissions cycles. Analysis of content and theme was done to identify the information applicants wished to be taken into consideration, and what range of adverse circumstances individuals reported.

METHODS

This study used a qualitative approach with thematic analysis to categorise the adversity statements. The data was initially analysed to create a coding framework which was then applied to the whole data set. Each coded segment was then analysed for heterogeneity and homogeneity, segments merged into generated themes, or to create sub-themes.

RESULTS

The data set comprised a total of 384 adversity statements. These showed a wide range of detail involving family, personal health, education and living circumstances. Some circumstances, such as geographical location, have been identified and explored in previous research, while others, such as long term health conditions, have had less attention in the literature. The degree of impact, the length of statement and degree of detail, demonstrated wide variation between submissions.

CONCLUSIONS

This study adds to the debate on best practice in contextual admissions and raises awareness of the range of circumstances and impact applicants wish to be considered. The themes which emerged from the data included family, school, personal health, and geographical location issues. Descriptions of the degree of impact that an adverse circumstance had on educational or other attainment was found to vary substantially from statements indicating minor, impact through to circumstances stated as causing major impact.

Are efforts to attract graduate applicants to UK medical schools effective in increasing the participation of under-represented socioeconomic groups? A national cohort study

INTRODUCTION

Attracting graduates was recommended as a means of diversifying the UK medical student population. Graduates now make up nearly a quarter of the total medical student population. Research to date has focused on comparing the sociodemographic characteristics of applicants to and/or students on traditional and graduate entry programmes (GEMs), yet GEMs account for only 40% of the graduate medical student population. Thus, we aimed to compare the sociodemographic characteristic and outcomes of graduates and non-graduate applicants across a range of programmes.

METHODS

This was an observational study of 117 214 applicants to medicine who took the UK Clinical Aptitude Test (UKCAT) from 2006 to 2014 and who applied to medical school through Universities and Colleges Admissions Service (UCAS). We included applicant demographics, UKCAT total score and offers in our analysis. Applicants were assigned as graduates or non-graduates on the basis of their highest qualification. Multiple logistic regression was used to predict the odds of receiving an offer, after adjusting for confounders.

RESULTS

Irrespective of graduate or non-graduate status, most applicants were from the highest socioeconomic groups and were from a white ethnic background. Receiving an offer was related to gender and ethnicity in both graduates and non-graduates. After adjusting for UKCAT score, the OR of an offer for graduates versus non-graduates was approximately 0.5 (OR=0.48, 95% CI 0.46 to 0.49).

DISCUSSION

Our findings indicate that the aim of diversifying the medical student population on socioeconomic grounds by attracting graduates has been only marginally successful. Graduate applicants from widening access backgrounds are less likely than others to be offered a place at medical school. Different approaches must be considered if medicine is to attract and select more socially diverse applicants.

'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.

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.

Role of students' context in predicting academic performance at a medical school: a retrospective cohort study

OBJECTIVES

This study examines associations between medical students' background characteristics (postcode-based measures of disadvantage, high school attended, sociodemographic characteristics), and academic achievement at a Russell Group University.

DESIGN

Retrospective cohort analysis.

SETTING

Applicants accepted at the University of Liverpool medical school between 2004 and 2006, finalising their studies between 2010 and 2011.

PARTICIPANTS

571 students (with an English home postcode) registered on the full-time Medicine and Surgery programme, who successfully completed their medical degree.

MAIN OUTCOME MEASURES

Final average at year 4 of the medical programme (represented as a percentage).

RESULTS

Entry grades were positively associated with final attainment (p<0.001). Students from high-performing schools entered university with higher qualifications than students from low-performing schools (p<0.001), though these differences did not persist at university. Comprehensive school students entered university with higher grades than independent school students (p<0.01), and attained higher averages at university, though differences were not significant after controlling for multiple effects. Associations between school type and achievement differed between sexes. Females attained higher averages than males at university. Significant academic differences were observed between ethnic groups at entry level and university. Neither of the postcode-based measures of disadvantage predicted significant differences in attainment at school or university.

CONCLUSIONS

The findings of this study suggest that educational attainment at school is a good, albeit imperfect, predictor of academic attainment at medical school. Most attainment differences observed between students either decreased or disappeared during university. Unlike previous studies, independent school students did not enter university with the highest grades, but achieved the lowest attainment at university. Such variations depict how patterns may differ between subjects and higher-education institutions. Findings advocate for further evidence to help guide the implementation of changes in admissions processes and widen participation at medical schools fairly.