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      Getting to know our non-traditional and rejected medical school applicants

      Perspectives on Medical Education

      Bohn Stafleu van Loghum

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Designing admissions policies to meet academic and non-academic selection aims while ensuring fair access proves challenging [1, 2]. Cleland et al. have previously described medical school admissions as a wicked problem, recognizing its complexity, describing selection as dynamic rather than a static solution [3]. Admissions policies are adjusted continuously in response to evaluations of their effectiveness as well as unintended consequences, such as effects on equity. The struggle between a meritocratic approach and the pursuit of equal opportunities is reflected in the rise of widening access criteria and widening participation initiatives to mitigate the effects of admissions policies on student diversity. Over the past years, concerns about inequalities in admissions have yielded an increase in research investigating the mechanisms through which non-traditional students (e.g., first generation higher education students, students from low socioeconomic backgrounds, etc.) might be disadvantaged and their aspirations affected by admissions practices. In this issue, Ball and colleagues contribute to our understanding of the experiences of these students. They observe that non-traditional applicants use social comparison to assess their suitability for the medical study and chances of success in the admissions process [4]. Their paper contributes to our understanding of the importance of role models. Furthermore, it raises questions about the effects being rejected may have on all applicants, both from non-traditional and traditional backgrounds. Previous research has shown the importance of role models, especially for non-traditional applicants who usually lack representation of people ‘like them’ in medical education and the medical profession [5–9]. The paper by Ball et al. brings to light how role models contribute to these applicants’ aspirations and confidence to apply to medical study. In addition, it reflects how non-traditional applicants’ limited sources of the different types of capital as described by Bourdieu (social capital—e.g. connections and networks; cultural capital—assets, e.g. competencies, skills, qualifications; symbolic capital—reputation and prestige, thus strongly dependent on how others see an individual; and economic capital—an individual’s wealth) can influence their confidence to apply [10]. A lack of medical connections, especially with similar backgrounds to theirs, makes it difficult for these applicants to prepare for selection [4, 6, 11] and envision themselves as being successful, all the more because they may encounter negative and discouraging reactions in their personal environment and have difficulty relying on their abilities and aspirations [4, 12]. Furthermore, these applicants have to draw upon sources outside their close network to be able to understand their position with regards to the selection criteria and their competitors. While other applicants may be able to draw upon various types of capital such as cultural (knowledge of the system and how to prepare) and social capital (obtaining relevant work experiences through their network), non-traditional applicants often have difficulties navigating the admissions process and lack relatable role models as sources for such capital [13, 14]. Without expert allies it is not surprising that they strongly rely and focus on non-social ‘objective’ test data, such as exam results [4]. In many countries, however, academic achievement is known to be subject to influences from students’ capital as well (e.g., attending a private or public school). As a result, both medical schools and applicants themselves may underestimate their academic ability. Uncertainty about their academic ability and strong emphasis on exam results to reassure their aspirations may deter non-traditional students from applying to medical school [15]. This accumulation of differences in capital between traditional and non-traditional applicants widens the gap and poses challenges to fair and accessible medical education [11]. The importance of non-social data to applicants may also have consequences further along the admissions process. If applicants are rejected, this rejection now becomes objective information which justifies their uncertainty and may guide future decisions to reapply. Research about factors influencing applicants’ choices to reapply is scarce, but personal perseverance and resilience seem important [4, 14]. Similar to the majority of selection literature, the study by Ball et al. was limited to students who had—eventually—been successful in selection. Lack of preparation was often their explanation for being rejected in previous rounds. If this is caused by their lack of knowledge of the admissions system (due to limited social capital) rather than an issue of poor motivation or unsuitability, these non-traditional students should not be discouraged to apply again. Furthermore, how applicants cope with rejection may differ between traditional and non-traditional students, as well as the resources they need or have available to do so. Drawing upon their available capital, traditional students may be better equipped to rebuild their confidence after rejection and reapply to medical school. However, non-traditional students, having overcome more barriers throughout their educational pathway (e.g., discrimination experienced by ethnic minority students [16]), may have built resilience to deal with rejection [5]. How applicants are effected by rejection warrants further research. It has been argued that non-traditional applicants may benefit from widening access activities which include guidance by mentors [4, 11, 14]. I advocate a longitudinal mentorship in which medical students who identify as non-traditional students themselves coach applicants. This allows for social comparison with a relatable role model, and could help these students acquire and utilize capital (e.g., building a relevant network, gaining understanding of the hidden curriculum) as they navigate both towards and through medical school [17, 18]. In conclusion, it is important to acknowledge the different admissions experiences, needs and reactions traditional and non-traditional applicants may have. In using the terms “non-traditional” and “traditional” students I do not mean to imply that these are homogenous groups. To ensure fairness and equal opportunities we need more insight into the variety of the experiences across the entire applicant population.

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          Most cited references 16

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          "Not a university type": focus group study of social class, ethnic, and sex differences in school pupils' perceptions about medical school.

          To investigate what going to medical school means to academically able 14-16 year olds from different ethnic and socioeconomic backgrounds in order to understand the wide socioeconomic variation in applications to medical school. Focus group study. Six London secondary schools. 68 academically able and scientifically oriented pupils aged 14-16 years from a wide range of social and ethnic backgrounds. Pupils' perceptions of medical school, motivation to apply, confidence in ability to stay the course, expectations of medicine as a career, and perceived sources of information and support. There were few differences by sex or ethnicity, but striking differences by socioeconomic status. Pupils from lower socioeconomic groups held stereotyped and superficial perceptions of doctors, saw medical school as culturally alien and geared towards "posh" students, and greatly underestimated their own chances of gaining a place and staying the course. They saw medicine as having extrinsic rewards (money) but requiring prohibitive personal sacrifices. Pupils from affluent backgrounds saw medicine as one of a menu of challenging career options with intrinsic rewards (fulfillment, achievement). All pupils had concerns about the costs of study, but only those from poor backgrounds saw costs as constraining their choices. Underachievement by able pupils from poor backgrounds may be more to do with identity, motivation, and the cultural framing of career choices than with low levels of factual knowledge. Policies to widen participation in medical education must go beyond a knowledge deficit model and address the complex social and cultural environment within which individual life choices are embedded.
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            Why people apply to medical school: implications for widening participation activities.

            This research aims to identify the influences contributing to students' decisions to study medicine and to apply the findings to the design and targeting of outreach activities aimed at widening participation. Semi-structured interviews were carried out with 15 medical students at a UK medical school. Framework analysis was used to identify themes and subthemes and findings relating to becoming a doctor were analysed further in the context of a theory of career decision making. Five themes and subthemes were identified. We report the results for the 3 main aspects relating to becoming a doctor from the theme School to Medical School Transition: early motivation; inhibitory factors, and facilitating factors. Many students spoke about having always wanted to study medicine. Early exposure to the possibility of being a doctor allowed the idea to flourish and motivated students to achieve high academic goals. Inhibitory factors included discouragement from application by teachers on the grounds of not being 'doctor material'. Factors which facilitated access to medicine included the support of family members, particularly mothers, and other close friends, and having positive role models. Our analysis provides evidence of important factors in career decision making for medicine which can be used to inform widening participation interventions in 3 areas, namely, those of school support, home support and raising aspirations.
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              Motivation of Dutch high school students from various backgrounds for applying to study medicine: a qualitative study

              Objective To explore high school students’ motivation for applying to study medicine and the factors that influence this. To find explanations for under-representation of minority students in medical education, descriptions of motivation of students with different background characteristics were compared. Design Qualitative phenomenological study using semistructured one-on-one interviews. Setting One predominantly white and one mixed high school in a large multicultural city in the Netherlands. The study was conducted in March–December 2015. Participants Twenty-four high school students, purposively sampled for demographic characteristics. Methods The analysis consisted of the coding of data using a template based on the motivation types (autonomous and controlled motivation) described by self-determination theory and open coding for factors that influence motivation. Results The main reasons for pursuing a medical career pertained to autonomous motivation (interest in science and helping people), but controlled motivation (eg, parental pressure, prestige) was also mentioned. Experiences with healthcare and patients positively influenced students’ autonomous motivation and served as a reality check for students’ expectations. Having to go through a selection process was an important demotivating factor, but did not prevent most students from applying. Having medical professionals in their network also sparked students’ interest, while facilitating easier access to healthcare experiences. Conclusions The findings showed a complex interplay between healthcare experiences, growing up in a medical family, selection processes and motivation. Healthcare experiences, often one of the selection criteria, help students to form autonomous motivation for studying medicine. However, such experiences as well as support in the selection process seem unequally accessible to students. As a result, under-represented students’ motivation decreases. Medical schools should be aware of this and could create opportunities to acquire healthcare experiences. High schools could incorporate internships as part of their study counselling programmes and offer tailor-made guidance to each individual student.
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                Author and article information

                Contributors
                a.wouters@amsterdamumc.nl
                Journal
                Perspect Med Educ
                Perspect Med Educ
                Perspectives on Medical Education
                Bohn Stafleu van Loghum (Houten )
                2212-2761
                2212-277X
                8 April 2020
                8 April 2020
                June 2020
                : 9
                : 3
                : 132-134
                Affiliations
                Faculty of Medicine Vrije Universiteit Amsterdam, Research in Education, Amsterdam UMC, Amsterdam, The Netherlands
                Article
                579
                10.1007/s40037-020-00579-z
                7283413
                32270368
                © The Author(s) 2020

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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