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I read with interest this article by Fielding et al regarding improving admissions to Medicine from under-represented groups. Neither low income background nor state schools applicants are proportionally represented by admissions currently, owing to the economic and social challenges of getting into medicine which disproportionately impact those from less affluent backgrounds (1).
In recent years, the approach to remedy this problem has been to get more people into interviews, through various means such as lowering GCSE requirements, guaranteed interview schemes, as well as charities that offer personal statement advice, which Fielding et al have recognised. Despite these measures, Fielding et al have demonstrated that modulating entrance exam criteria produces no discernible effects on overall admissions from low income backgrounds (2). This should be a red flag to admissions officers, demonstrating that removing barriers to interview is not sufficient to fix this problem.
To understand the problem better, consideration must be given to interview development. More medical schools are moving towards the use of multiple mini interviews (MMIs). Each MMI station is blueprinted to assess a few specific desirable skills and attributes. It is felt that this process eliminates bias and makes judgements more context specific (3). On principal, this should mean that socioeconomic advantage would not factor into MMI performance, as more affluent...
To understand the problem better, consideration must be given to interview development. More medical schools are moving towards the use of multiple mini interviews (MMIs). Each MMI station is blueprinted to assess a few specific desirable skills and attributes. It is felt that this process eliminates bias and makes judgements more context specific (3). On principal, this should mean that socioeconomic advantage would not factor into MMI performance, as more affluent applicants cannot simply pay to acquire skills. Or can they?
More affluent students will have more money to pay for interview workshops, have specialised coaching at school, have a wider pool of alumni to consult, not to mention the high density of medical parents who can give advice and offer medical experience. It’s a snowball of class-based affordances; you’re more likely to get an interview and given more guidance in succeeding at interview. Whilst a less affluent applicant may have comparable experiences, and thus would theoretically perform equally well at interview, they are likely to be less aware of what the blueprinted skills for stations are, and thus less able to gear answers toward point-scoring, even with comparable enthusiasm and suitability for medicine. This is supported by research by Lambe, Waters and Bristow, who found that prior coaching significantly predicted medical interview scores (4).
One could argue that stations based on practical skills (e.g. breaking bad news) are more fair, given that anyone could be an effective communicator. However, unlike more general stations, acting stations normally have specific marking points. Whilst applicants may be good communicators, we are once again in a situation where applicants who are more affluent may be more privy to the ‘dos and don’ts’ of these stations.
It therefore feels absurd to believe that moving the goalposts to obtain an interview will somehow improve representation, when interviews are unfortunately still more accessible to people from more affluent backgrounds. This is substantiated by widening participation reports, that the numbers of state school entrants into medicine has not significantly varied since 2007 (1).
Widening participation schemes may be a way to alleviate this problem, however, they are geographically and financially restricted. On the other hand, online you will find tutors offering advice from “doctors who teach at UK medical schools”; of course for a fee, thus giving monopoly to richer students. It is deeply troubling that there are people profiting from inequalities in education. This leaves a serious rift of applicants who can neither afford help, nor meet requirements to receive it.
A good way to address the problem of knowledge access would be for greater transparency in interview assessment criteria across all medical schools. In being more transparent about what interviewers look for, medical schools would truly be equalising the opportunity to excel at interview amongst students from all backgrounds. This view is supported by Klehe et al, who demonstrated that interviews with greater transparency resulted in better candidate performance and importantly, greater construct validity, suggesting that transparency would make MMIs more robust determinants of strengths and weaknesses (5).
Fielding et al were correct in highlighting the problem of inequalities in admission to Medicine; having a population of doctors that does not reflect the population they work in continues to pose serious consequences. However, this inequality will continue to plague medicine until serious consideration is given to how the system favours more affluent applicants.
1) Medical Schools Council (2018) Selection Alliance 2018 Report. (https://www.medschools.ac.uk/media/2536/selection-alliance-2018-report.pdf)
2) Fielding S, Tiffin PA, Greatrix R, et al Do changing medical admissions practices in the UK impact on who is admitted? An interrupted time series analysis BMJ Open 2018;8:e023274. doi: 10.1136/bmjopen-2018-023274
3) Rees EL, Hawarden AW, Dent G, Hays R, Bates J & Hassell AB (2016) Evidence regarding the utility of multiple mini-interview (MMI) for selection to undergraduate health programs: A BEME systematic review: BEME Guide No. 37, Medical Teacher, 38:5, 443-455, DOI: 10.3109/0142159X.2016.1158799
4) Lambe P, Waters C & Bristow D (2013) Do differentials in the support and advice available at UK schools and colleges influence candidate performance in the medical school admissions interview? A survey of direct school leaver applicants to a UK medical school, Medical Teacher, 35:9, 731-739, DOI: 10.3109/0142159X.2013.801941
5) Klehe U, König CJ, Richter GM, Kleinmann M & Melchers KG (2008) Transparency in Structured Interviews: Consequences for Construct and Criterion-Related Validity, Human Performance, 21:2, 107-137, DOI: 10.1080/08959280801917636