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commentaries
4

Friedman CP, Gatti GG, Franz TM,


Murphy GC, Wolf FM, Heckerlings
PS, Fine PL, Miller TM, Elstein AS.
Do physicians know when their
diagnoses are correct? Implications
for decision support and error
reduction. J Gen Intern Med
2005;20:3349.
Elstein AS. Heuristics and biases:
selected errors in clinical reasoning. Acad Med 1999;74(7):7914.
Gigerenzer G, Todd P, ABC
Research Group. Simple Heuristics
That Make Us Smart. New York:
Oxford University Press 1999.

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Eva KW, Regehr G. Self-assessment


in the health professions: a reformulation and research agenda, in
press.
Gilovich T. How We Know What Isnt
So: the Fallibility of Human Reason in
Everyday Life. New York: The Free
Press 1991.
Schacter DL. The Seven Sins of
Memory. How the Mind Forgets and
Remembers. New York: HoughtonMifflin Company 2001.
Wilson TD. Strangers to Ourselves:
Discovering the Adaptive Unconscious.
Cambridge, MA: The Belknap

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12

Press, Harvard University Press


2002.
Hatala R, Norman GR, Brooks LR.
Influence of a single example
upon subsequent electrocardiogram interpretation. Teach Learn
Med 1999;11:11017.
Norman GR, Brooks LR, Colle CL,
Hatala RM. The benefit of diagnostic hypotheses in clinical reasoning: experimental study of an
instructional intervention for forward and backward reasoning.
Cogn Instruct 2000;17:43348.

Outreach is better than selection for increasing diversity


John C McLachlan

Students admitted to medicine in


the United Kingdom do not
match the national profile of
social and ethnic diversity.1,2 This
is not just harmful from the point
of view of equity: there is evidence
that candidates from particular
cultural backgrounds work more
effectively within that background,
and thereby produce better health
care indicators for society as a
whole3.
Addressing these imbalances has a
high political priority, evidenced by
the introduction of the Office of
Fair Access (OFFA), which can
prevent institutions without an
acceptable widening participation
strategy from charging full fees4.
Government statements suggest
that OFFA will pay particular
attention to socio-economic disadvantage. There are therefore prac-

Peninsula Medical School, Plymouth, UK.


Correspondence: J. C. McLachlan, Professor of
Medical Education, Peninsula Medical School,
C306 Portland Square, Plymouth PL4 8AA, UK.
Tel. +44(0)1752238005; Fax: +44(0)1752 238000;
E-mail: john.mclachlan@pms.ac.uk
doi: 10.1111/j.1365-2929.2005.02257.x

tical financial reasons for medical


schools to widen participation, in
addition to considerations of social
equity and health care.
Factors limiting access to medicine
have been studied insufficiently.
For access to higher education in
general, social class is the main
predictor of academic achievement.5 Because medical courses
are significantly longer, there is
likely to be an additional disincentive for disadvantaged groups.6
Finally, societal and family expectations are significantly different
within different backgrounds.5 As
a consequence, applicants to
medicine and dentistry are significantly skewed in their class composition (Table 1).
There are three components to
widening participation. The first is
outreach, to encourage a greater
diversity of candidates to apply.
The second is selection, to ensure
that candidates are not disadvantaged by their background. The
third is retention, to ensure that
candidates from disadvantaged
backgrounds do not suffer
disproportionate hardships leading

to higher drop-out rates, particularly with regard to long medical


courses.
Because medicine has many more
applicants than places, selection is
the best studied of these components. Affirmative action strategies
to address historical imbalances
are, however, politically and ethically controversial. In the United
States there has been a tradition of
affirmative action for certain categories of candidates. The rationale
for this has been that the societal
imbalances for some social groupings have been so great that selection based on academic
performance is in itself discriminatory. While there have been challenges to this approach, the most
recent ruling from the Supreme
Court (July 2003) is that affirmative
action is legal and not an infringement of the rights of others as long
as it is individual and not the sole
basis of selection.3 Guidance within
the United Kingdom also suggests
that while applicants cannot be
treated differentially on the basis of
their background, individual circumstances can be taken into
account.7

 Blackwell Publishing Ltd 2005. MEDICAL EDUCATION 2005; 39: 872875

873

Table 1 Applications and acceptances to medical and dental schools in the United Kingdom by socio-economic status, 2003*
% of working-age
population

Socio-economic group
Higher managerial and professional
Lower managerial and professional
Intermediate occupations
Small employers and own account workers
Lower supervisory and technical occupations
Semi-routine occupations
Routine occupations
Unknown
Total

10
22
10
8
9
13
10
17

Applications

Acceptances

% Acceptances

4630
3439
1290
577
295
821
274
2257
13 583

3001
2009
741
342
165
443
143
980
7824

64.8
58.4
57.4
59.3
55.9
54.0
52.2
43.4
57.6

*Data from UCAS2.

Of course, there is widespread


agreement that medical students
should be admitted primarily on
merit: but no one has established
how merit can be measured in
absolute terms. In the United
Kingdom, most applicants are
admitted after they have completed
secondary education at age 18, and
admission requires very high levels
of academic performance. However, there are two drawbacks to
this approach.
selection at the top endmay result
in the admission of students who are
poorly suited for medicine

First, selection at the top end of the


distribution may result in the
admission of students who are
poorly suited for medicine810 and
may decrease diversity.7,11 Otherwise, for the population of medical
students as a whole, there is a
correlation between success in
medicine and academic qualification on leaving school.12 No contradiction exists between these two
sentences: the latter sentence confirms that doctors tend to be clever
people; the former indicates that
clever people do not necessarily
make good doctors.

Secondly, academic performance


is in part a reflection of past
social and cultural opportunities.
Applicants from independent
(private and fee-paying in the
United Kingdom) schools have an
unjustified advantage at the point
of admission.7 This is most
marked when independent
schools are compared with (statefinanced) Local Education
Authority (LEA) schools. After
admission, the independent
school cohort underperforms
consistently and significantly compared to students from state
schools admitted with the same
qualifications. For instance,
approximately 50% of independent school pupils admitted with
22 A-level points obtained a First
or Upper Second, compared with
approximately 60% of LEA pupils
admitted with the same score.
academic performance is in part a
reflection of past social and cultural
opportunities

As selection by academic performance alone is flawed, additional


measures of aptitude for medicine
are generally sought. These
include personal statements by

 Blackwell Publishing Ltd 2005. MEDICAL EDUCATION 2005; 39: 872875

applicants, references, work


experience in health-care settings
and interviews. These do not, of
themselves, address the issue of
widening participation, and the
last column in Table 1 reveals that
acceptance rates for medicine and
dentistry vary adversely with socioeconomic standing. Recent changes in the way in which socioeconomic status is calculated in
the United Kingdom make historical comparisons difficult, but
there are signs that improvement
is occurring, if slowly.
However, attempts to improve the
fairness of selection methods, while
an intrinsic good, are not the most
effective way of improving participation rates. Table 2 shows the
consequences of applying the same
percentage acceptance rate to all
socio-economic groups. Choosing
the average acceptance rate
(57.6%) results in no overall
increase in the number of acceptances.
The impact of this is that the
number of acceptances in the
higher managerial and professional group falls from 3001 to
2667, while the number of acceptances in the routine occupations
group rises from 143 to 158. The

874

commentaries

Table 2 Applications and calculated acceptances to medical and dental schools in the United Kingdom by socio-economic status,
assuming the same acceptance rate across socio-economic groups
Socio-economic group

Applications

% Acceptances

Acceptances

Higher managerial and professional


Lower managerial and professional
Intermediate occupations
Small employers and own account workers
Lower supervisory and technical occupations
Semi-routine occupations
Routine occupations
Unknown
Total

4630
3439
1290
577
295
821
274
2257
13 583

57.6
57.6
57.6
57.6
57.6
57.6
57.6
57.6

2667
1981
743
332
170
473
158
1300
7824

redistribution is therefore rather


modest. In Table 3, by contrast, the
acceptance rates have been kept at
their current unfair distributions,
and the number of applications has
been matched to the size of the
socio-economic group, using the
highest participation rate. This is a
hypothetical calculation for illustrative purposes only. Because it has
the theoretical effect of vastly
increasing the number of applications, the acceptances column has
been adjusted proportionately to
give the same total of acceptances
as in Table 1.
This has more dramatic consequences. The number of accept-

ances in the higher managerial


and professional group falls from
3001 to 931, while the number of
acceptances in the routine occupations group rises from 143 to
750. While these figures are for
illustration only (it is unrealistic
to think that the number of
applications could rise to over
45 000), they suggest that
improving application rates
addresses imbalances more
powerfully than increasing fairness. This will be a familiar concept to public health physicians:
extending screening from a small
subgroup to the whole population
is more beneficial than a small
increase in sensitivity.

This hypothetical calculation suggests that such an approach is


unlikely to lower standards. With
3.5 million people of working age
in the routine occupations socioeconomic grouping, it is inconceivable that 750 genuinely meritorious candidates could not be
found annually. Finally, it is politically much less contentious to
boost application numbers than
to have differential selection
methods.
it is politically much less contentious
to boost application numbers than to
have differential selection methods

Table 3 Applications and calculated acceptances to medical and dental schools in the United Kingdom by socio-economic status,
assuming the same application rate across socio-economic groups but the same success rate per group as in Table 1
% of working-age
population

Socio-economic group
Higher managerial and professional
Lower managerial and professional
Intermediate occupations
Small employers and own account workers
Lower supervisory and technical occupations
Semi-routine occupations
Routine occupations
Unknown
Total

10
22
10
8
9
13
10
17

Applications
4630
10 186
4630
3704
4167
6019
4630
7871
45 837

Notional %
Acceptances
64.8
58.4
57.4
59.3
55.9
54.0
52.2
43.4

Acceptances*
931
1846
825
681
723
1008
750
1060
7824

*Adjusted proportionately to give the same total of acceptances as in Table 1.

 Blackwell Publishing Ltd 2005. MEDICAL EDUCATION 2005; 39: 872875

875

In the light of this, it is encouraging that a number of interventionist approaches have been
taken in an attempt to improve
participation rates. In 2004, the
Higher Education Funding Council for England last year awarded a
total of 9 million for outreach
projects in the United Kingdom.
Particular interest has focused on
programmes featuring student
mentoring of potential applicants,
with 1.5 million allocated to
mentoring schemes aimed at
increasing diversity in those
entering medical and health professions.
It would be desirable to demonstrate that such mentoring has a
statistically significant positive
impact. The paper by Kamali et al.
in this issue offers evidence in
support of this concept. Students
from educational settings traditionally under-represented in
medicine were allocated to two
groups. One group received active
guidance and assistance in gaining
work experience from their student volunteer mentors, the other
received advice only, without active help in organising experiences. The former group
subsequently performed significantly better in terms of offers
being made of places at medical
school.
The research design was compromised by the fact that both groups
received additional training in
interview techniques. This may
have contributed to the increased
number of offers received by both
groups of students over historical
levels. Here the authors are
encountering, but not resolving, a
classic ethical dilemma of medical

research. As the long-term aim of


the project was to improve participation rates, it can be morally
challenging to withhold a potentially beneficial intervention from
some participants, especially as
mentors and staff are volunteers,
and therefore probably enthusiasts
for widening participation. However, the resolution of this moral
dilemma lies in the observation
that any innovation under investigation has a chance of proving
inferior to the standard approach,
no matter how unlikely this seems
to proponents of the new way.13
As the authors themselves emphasise, this study is of small scale, and
would benefit from expansion and
replication. None the less, it is an
encouraging finding which provides not only evidence for the
value of mentoring as an intervention to increase participation
rates but also, in the first part of
the study, a simple and robust
quantitative methodology which
could be applied to other circumstances.

10

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