Admission to medical school is not the endpoint of widening participation
1University of Glasgow, Glasgow, UK
Scholarly papers addressing widening access and participation in medicine have mushroomed in the last decade or so, but the focus has predominantly been on the first part of the equation: access. The time has come to consolidate the gains in widening access and develop the latter half of the equation and ensure equitable participation of students from non-traditional backgrounds. Academic discussions about class and social mobility concentrate on understanding the factors that determine (or limit) people’s upward trajectory and how class origins still play a strong role in it. This paper builds on a critical evaluation of the published literature on the topic to discuss the barriers (perceived or real) that students from widening participation backgrounds experience on their journey from admissions to progression through to medical training and into the workforce. It is discussed what tangible measures can be taken to break the cycle of social reproduction and help students from disadvantaged backgrounds successfully enter the medical professions.
widening access, diversity, transition to university,
barriers to access, social/economic/cultural capital, imposter syndrome
Background: widening access to the medical professions
Rising inequality in the UK has brought the idea of social justice into sharper focus, resulting in the last government’s ‘levelling up’ strategy (Department for Levelling Up, Housing and Communities, 2022) among other initiatives. Long before the ’levelling up’ was launched, however, universities had started addressing the issue of widening participation (WP) and fair access to all courses including medicine.
WP policy is multifaceted and has international dimensions: in Canada and Australia it mainly focuses on their indigenous populations (Coyle et al., 2020; Gore et al., 2017; Rees et al., 2022), while in Germany the issues are more about what sociologists call micro-class reproduction, the term used for the phenomenon that those with parents in the medical profession perpetuate through generations by becoming medical professionals themselves (Symmenroth-Nayda, 2015). In the United Kingdom (UK), WP relates to prospective students from low socio-economic backgrounds, who often attend schools or colleges with lower than national average progression rates or can be about students’ care experience (being in care/being a carer) (Universities and Colleges Admissions Service, 2022; Office for Students, 2022). In all cases, widening participation policy is about equal opportunity to gain admission to what have traditionally been ‘elite’ subjects (such as medicine, law, and finance).
In the UK, those of working class backgrounds make up approximately one sixth of people in elite occupations (Friedman & Laurison, 2019), while those from upper-middle class origins occupy fully half of the top jobs and have a five to six times higher chance of landing an elite job compared to people from a working class background (Bukodi et al., 2015). These figures show the paucity of social mobility in the UK and the trend is not improving: 73% of those surveyed in 2016 said it was fairly difficult or very difficult to move between social classes, compared with 65% in 2005 (Evans & Mellon, 2016). Yet, the numbers are even worse for medicine: while 60% of the British population consider themselves working class (Butler, 2016; Evans & Mellon, 2016), only 4% (Social Mobility Foundation, 2017) to 6% (Friedman et al., 2017) of doctors are from a working-class background. The picture is hardly better for other elite professions – law, journalism, architecture, academia – all have a high percentage of people from privileged backgrounds (Arnett, 2014; Lee, 2016; Moravec, 2015; Social Mobility Commission, 2019; Weale, 2016).
Medical schools vary in history, status, and origins as well as in course design and delivery, but all see a preponderance of enrolled students coming from the higher socio-economic strata (Le, 2017; Youngclaus & Roskovensky, 2018), despite only 6% of the general population belonging to the high socio-economic classes (Savage et al., 2013; Thomson, 2016). Medicine thus remains, by most definitions, elitist. To a large extent, this persistence is linked to the different social and cultural capital (supported by financial capital), that is accrued by people from different backgrounds. Those from families with professional backgrounds often have (or are able to initiate) valuable contacts. They can leverage opportunities to increase their chances of being accepted into medical school, e.g., placement/shadowing opportunities accessed through their (families’) networks. Even simply by knowing the ‘rules of the game’ of university admission and possessing specific privileged knowledge not available to working class applicants or their parents, they are well ahead. The advantage is built-up further by attending the ‘right’ (selective) schools and pursuing extracurricular activities or paying for training courses (e.g., aptitude tests), that are out of reach for working class students. The latter will have accrued social and cultural capital too, but it typically does not match to what the selectors might value and look for when interviewing applicants for the limited number of medical school places, especially since most interviewers – being clinical doctors – likely also originate from the higher social classes themselves.
While only 7% of children in the UK attend private schools (Goodall, 2017; Sellgren, 2014), 27% of all medical school students are educated privately (Carrell, 2016; Coughlan, 2018; Rees et al., 2022). These schools are well resourced and have ‘medical societies’, providing a holistic and sustained support for pupils aspiring to the medical professions, in addition to access to privileged knowledge, social capital and in some cases opportunities to do short placements in General Practice (GP) practices or clinics. Clearly, the advantages for the students from higher classes make the applicants from non-traditional backgrounds less competitive for admission to medical schools seeking to recruit the most promising (re: continuation/graduation) cohort. In terms of black and minority ethnic (BME) representation, inequality is manifested in the National Heath Service (NHS) workforce statistics – only 5% of doctors at all grades are from BME origin and the number is even lower at the level of consultants (3.6%) (NHS Digital, 2021).
To increase diversity in the medical school student body, various WP policies have been initiated nationally: outreach to low participation schools, summer schools (British Medical Association, 2021; Medical Schools Council 2022) or 1-year gateway courses to prepare prospective students from lower socioeconomic background for the first year of the medicine course (Imperial College London, n.d.; University of Birmingham, n.d.; University of Glasgow, n.d.) etc. The general drive to widen participation of underrepresented groups has now resulted in a substantial increase in admission of students from a WP background (Pooran, 2022). However, inequalities remain, and not just in accessing but also in succeeding/progressing on the undergraduate course through post-graduate training. Indeed, the disadvantages still faced by potential applicants after selection by the medical schools are largely overlooked, and insufficiently addressed.
This discussion paper considers the understanding of the barriers (perceived or real) the students from a WP background experience on their journey from admissions to progression through to medical training and into the workforce. The perspectives of students and staff on these issues are compared. The paper also covers the concept of the ‘imposter syndrome’ students often mention. It draws on the existing literature on the subject and links it with student success.
Recently, a study surveying students from three distinct medical schools in the UK (Sartania et al., 2021) reported that more targeted support from parents and schools is required to equip the students from non-traditional backgrounds with the skills to secure admission to the medical school and then succeed on the course. Students remarked on a lack of structured support; not just from their secondary schools, but also from the medical schools where more academic tutoring and help in honing their study skills appears to be needed, especially in the transition phase. A lack of financial support dominated the list of the barriers students mentioned as many of them juggle part-time work and family responsibilities alongside studies. This situation will only exacerbate in the current cost of living crisis, leaving the students from a WP background, specifically, to fend for themselves to challenge their growing disadvantage with little support from anyone. The other issue that prominently featured in students’ returns concerned peer networks. They felt that ‘the safety net’ that a peer network can provide could ameliorate some of the inevitable issues these students face in the university before and after admissions. It is especially beneficial when senior peers from a similar background provide mentoring to their more junior colleagues, but students from a WP background will find fewer peers from their old schools, for instance, than students from private schools will. Andrews and Clark (2011) documented that peer mentoring enables students to make the most of the academic opportunities available to them and helps support their mentees in ‘learning how to learn’, while the mentors also benefit from the experience.
It has been argued before that the different sets of social, cultural, and economic capital, accrued by people through their upbringing and different life journeys allow them to be successful in certain fields (Friedman & Laurison, 2019; Sartania et al., 2021) and that this leads to social reproduction (Jonsson et al., 2009). One important factor is the constellation of ‘symbolic mastery’ (Bourdieu, 1986) that places the well-off students in the ‘right’ category for elite careers, as these are recognised by the selectors who subconsciously exercise homophily and look for a similar background to themselves in an applicant – someone who presents themselves well and will ‘fit in’ in the existing social framework. This is echoed by students from widening participation backgrounds when they talk about ‘imposter syndrome’ and feeling like a ‘fraud’ among the more affluent peers on the medicine courses. The students experience a mismatch between the identity conferred by their backgrounds and the identity they feel they now need to adopt, as a student on a prestigious course. The journey of upward social mobility is particularly difficult for groups where intersectionality applies, i.e., multiple disadvantages experienced by a single person (Guttierez et al., 2022). For instance, women from a lower socio-economic or minority ethnic background, or a person from racial-ethnic group with a disability might struggle to navigate the pathways to an elite profession. Attributes such as low participation school, care experience or residence in one of the 20% most deprived postcodes are referred to as WP flags. It is difficult to attribute which specific factor confers the most disadvantage, but it is clear that the students’ experiences of disadvantage vary with the number of the WP flags they possess (Sartania et al.,2021).
The more WP flags the student had, the more they were likely to have lacked structured, dedicated support from the schools they had attended, which were often poorly resourced; they felt ill informed about the application process and had missed out on opportunities that would have advanced their application. Not only was there insufficient support to attain the necessary grades for admission, but also to navigate the selection processes, train for interviews, familiarise themselves with aptitude tests, practise to write personal statements and obtain relevant work experience. It is not only the mismatched cultural capital that manifested itself at selection interviews, but also in interactions with their more affluent peers once on the course, contributing to the feeling of ‘not fitting in’. The students commented on the ability of those from the better schools, who have received more study skills training, to understand and meet the university’s demands more easily and succeed with work that require self-directed study and self-motivation (Sartania et al., 2021).
It seems that the relationship norms between the students from working class and affluent backgrounds differs (Manstead, 2018). The former rely strongly on interdependency (learning to work together; community of learners with a common goal), while the middle-class students put greater emphasis on independent norms (e.g., self-directed/self-regulated learning) – the very traits expected of students once they start university. At a social and cultural level as well, WP students might often feel they cannot participate in some conversations about extracurricular activities, e.g., skiing holidays or concerts, that they have neither the time nor the financial means to participate in. All these factors contribute to issues of self-confidence and anxiety for WP students in the medical school environment. This anxiety about ‘belonging’ may sometimes lead to even larger perceived differences than exist in reality, but this still undermines confidence and has a real impact. This unease is commonly referred to as ‘imposter syndrome’.
Stephens et al. (2015) discuss a number of steps that would help reduce working‐class students’ perception of not fitting in with their university environment. This includes staff cultivating a sense of belonging (a community of medics at X university with common values), providing working‐class role models and employing teaching methods that build on the interdependency that is a cultural norm for students from widening participation backgrounds. This should include the use of teaching methods that involve collaborative group work; setting tasks for learning in community groups; designing assignments that can be done in mixed groups etc; and ensuring that the WP students have a voice, for example, by providing forums in which they can express shared interests and concerns. Establishing a WP society within the school that has social functions, and also a direct line of feedback to senior school staff, enables an increased sense of belonging as its meetings provide an opportunity for peer networking across the different academic year groups, as well as the empowerment that comes with direct consultation and interaction with faculty staff.
As also alluded to above, the feelings of 'not fitting in' are exacerbated by these students’ lack of economic capital too, which often excludes them from many social, leisure and sports activities, including conversations about such activities. In the recently published survey (Sartania et al., 2021) these students often talk about the need to work part-time for extra income, or about having caring duties, and that this leaves them too tired to socialise, leading to the perpetuation of their social capital deficit and further isolation. The necessity for paid work or to provide care to a family member puts further stress on any time these students might have beyond the requirements of the course. If affordable, some universities offer a start-up financial support to their students from disadvantaged backgrounds at the start of the course (e.g., University of Southampton, n.d.), which is welcome but does not negate the need for income during term-time.
In order to effectively support students from the various widening participation backgrounds, it is vital that staff understand the actual and perceived barriers the students face during their medical education. It must be acknowledged, however, that demands on clinical staff time are high, which makes it hard for them to notice and appreciate the needs of students in full, never mind address them. On the other hand, teaching staff that work closely with students and see them regularly (core faculty), can have huge influence in mentoring, supporting, and motivating students, helping them build confidence and accrue soft skills. Frequent interactions to pre-empt or ameliorate issues, timely pastoral care, and links within the peer network, could serve staff well too as it is hard to provide support if it is not clear what the issues are.
To address the question and complement the study on students’ perception of barriers to access and success on the course, we have recently surveyed staff from different job categories (academic, clinical staff, and professional services) about their perception of barriers for students from a WP background (compared to others). This work (Sartania et al., 2022), which is still progressing, revealed that staff have a good grasp about the early outreach programmes, i.e., the initial support for students at (and leading up to) the application stage to medical school (help with interview skills, personal statement). However, there was a conspicuous lack of understanding of the continued difficulties these students experience once on the course. Some of the clinical educators were rather harsh and stereotyping, with comments implying that students from a widening participation background lacked work ethics and/or time management skills, but did not take into consideration that many of these students work part-time and may have caring responsibilities besides their studies.
It is interesting that, while staff perceive the lack of finances as a barrier, they place this mostly in the context of a lack of extracurricular opportunities, whereas the WP students themselves mention being worried about not having enough money to live on and needing to take part-time jobs to sustain themselves. There is a discrepancy also in understanding the nature of family support. Students believe they have the strong moral support from home; it is not a supportive attitude, but privileged knowledge and contacts that their families lack. Thus, although similar themes were highlighted by staff and students in our comparative on-going study, they meant quite different things to the two groups, with the potential for misunderstandings.
The comments from some clinical educators that ‘...they [WP students] shouldn’t have any problems now that they gained a place’ appeared to indicate a disconnect. While it is correct that the course is equal in content for all students, it disregards the differences in circumstances the students from a widening participation background face, as well as the more intangible issues of self-confidence and imposter syndrome. It would be of interest to investigate perceptions of the foundation years students from a WP background to understand whether they feel they are proportionally represented in the more popular specialties, and on the more prestigious training programmes at sought after locations.
Many medical schools are interested in differential attainment of students from a WP background and whether their progression rate influences clinical training opportunities after the university. Curtis and Smith (2020) provide modest evidence in support of the gateway programmes as the means of achieving success on the MBChB degree. They report that the differences in the available outcomes on exit between ‘gateway’ students and ‘standard entry’ students on the three oldest gateway programmes are statistically not significant: both cohorts complete the primary medical qualifications and enter the foundation years. Not much is currently known about their career destination thereafter or the time spent in training and what specialty choices they make. They are often overrepresented in general practice (Lowe, 2019) but is not clear whether that is by choice or from a lack of other options.
This is especially important because students from a WP background might have limited insight into the career routes after graduation and what is needed to progress well in their future careers. It is important to remember that the ‘imposter syndrome’ the students from a WP background talk about in their survey returns might deter them from choosing to train in the more prestigious specialties of the medical hierarchy, which in turn would result in a suboptimal final career path.
Class still matters a great deal for whether one achieves the best outcomes from their degree. It matters whether the WP student attends a Russell group university (the most research intensive universities in the UK), whether they engage in research or audit while at university, or if they take elective studies abroad (again, mostly done by financially better provided students).
Even then, these on their own may not have the desired effect, unless they also get guidance and support from those ‘in the know’. Encouragement and motivation and role modelling will have a very positive effect on getting these students through their preclinical education and foundation years and seeing them prosper and integrate well into the medical workforce community.
While all graduates are guaranteed foundation year training posts upon graduation, the route into the training varies for students; those from a WP background might have lower educational performance measure (EPM) and/or situational judgment test (SJT) scores – the two measures that determine whether the graduate will get their first choice job as a trainee. Even if they do as well as their better off peers in EPM and SJT, a lack of confidence may have the effect that they ‘sort’ themselves into ‘the right fit’ jobs instead of applying for more competitive positions. They may also be deterred by the lack of finances, as moving to more expensive parts of the country for the most prestigious training placements will require significant amounts of money for rent, relocation, insurance – all this before the newly qualified doctor receives their first renumeration. We thus see that economic capital remains a theme throughout the entire journey from a WP student into a WP medical professional. Staff from all job categories we surveyed appeared not to have a full grasp of the barriers at this stage, as they think the WP students are on a par with the rest of the cohort at graduation, having gained the same qualification. This opinion seems to be at odds with the frequency of the themes such as confidence/imposter syndrome/lack of social capital discussed by staff, and with the notion of social isolation brought to our attention by the WP students in our previous study (Sartania et al., 2021).
The material circumstances the students from a WP background develop and grow up in, influence the way they project themselves. Perhaps it is not easy to break those barriers but with the educational and employment opportunities they are pursuing, they will be able to address their disadvantage and break the cycle of social reproduction. It is hoped that increased awareness and understanding of the issues these students face will further boost the efforts of medical schools’ staff (both clinical and academic) to address social mobility issues and lead to concrete measures to challenge them; recruiting as wide a pool of diverse interviewers as might be available, given the uneven class distribution of current medical practitioners, and providing them with equality, diversity and inclusion training and a clear understanding of the school’s strategy on recruitment will minimise bias, unconscious or otherwise. The driving force remains that, alas, this is an important societal problem that must be tackled to achieve social cohesion. At a time when economic inequality is increasing across the globe (Partington, 2019; Ventura, 2022), and certainly in the UK (The Equality Trust, n.d.), the lack of mobility cements class differences, leads to despondency and demoralisation, and puts a strain on society. Most people would engage in civic conversations to support government policies designed to narrow the gap between the classes. Given that the uneven distribution of power, opportunity, resources is the fundamental driver of this class difference, widening participation in higher education remains essential to create greater equality.
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