Widening interest, widening participation: factors influencing school students’ aspirations to study medicine

Widening interest, widening participation: factors influencing school students’ aspirations to... 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. Keywords: Widening participation, Selection, Medical careers, Widening access, Medical school admissions * Correspondence: bryan.burford@newcastle.ac.uk School of Medical Education, Newcastle University, Ridley Building 1, Newcastle-upon-Tyne NE1 7RU, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Martin et al. BMC Medical Education (2018) 18:117 Page 2 of 13 Background Literature has considered how to encourage wider ap- The under-representation of students applying for plications, for example information outreach [17]. How- and studying medicine from less advantaged socio- ever, some admissions staff have concerns about the economic backgrounds is an ongoing area of con- impact of Widening Participation on medical school cern. Across the countries of the UK, approximately reputation and view it negatively, ranging from a 75% of applicants to medicine have a parent in the box-ticking exercise to undesirable social engineering highest occupational socio-economic group, and [18]. Schools also neglect to evaluate the impact of Wid- 19.7–34.5% applicants live in the most affluent post- ening Participation activities [18]. This may in part ex- code decile versus 1.8–5.7% in the least affluent [1]. plain why there has been limited impact reported to The issue has been raised by governmental reports date [19]. into social mobility [2, 3] and the Medical Schools This project aimed to identify barriers or deterrents to Council, the corporate body for medical schools, is applying for medical school perceived by prospective examining how recruitment processes may address medical students and explore how those barriers may be this imbalance following its ‘Selecting for Excellence’ addressed, at what stage in school careers, and by which report [4]. This is not only a concern in the UK, but agency. has been described and prioritised internationally [5–9]. Research questions ‘Widening Participation’ (WP) is used to describe both The project was designed as exploratory research to the principle of increasing engagement in medical edu- consider the broad research questions ‘What barriers to cation and the schools and students who are targeted application to medical school are identified by school through related initiatives. Encouraging and facilitating students?’ and ‘What actions, and by which agencies, applications from all sections of society may benefit the may mitigate those barriers?’. The focus is on under- workforce by presenting a wider pool of applicants with- standing students’ perspectives, rather than evaluating out the need to reduce standards [10]. Doctors recruited existing interventions. from lower socio-economic status (SES) backgrounds are more likely to work in deprived areas [11] and pur- Context of the study sue under-supplied careers such as general practice [12]. This project was embedded within the timetable of an Medicine is typically regarded as a ‘selecting’ rather existing programme of Widening Participation activity than ‘recruiting’ subject, with more applicants than delivered by the Faculty of Medical Sciences at New- places. However, under-represented groups are also castle University – Medicine and Dentistry (MaD) under-represented in applications. Of those taking days – to access participants. However, the research the United Kingdom Clinical Aptitude Test was developed and conducted independently of the (UKCAT), required by most UK medical schools for organisers of the MaD days. school-leaver entry, 80% come from higher socioeco- MaD days, which are held in Newcastle University nomic groups [1]. Students from fee-paying private Medical School, offer didactic and practical sessions for schools are more likely to be accepted into medicine school students in Year 9 (age 13–14) and Year 12 (age independent of academic achievement [13]. Medicine, 16–17). Three days per year group take place each aca- dentistry and veterinary science are the university demic year. Those attending Year 12 MaD days have subjects with the lowest proportion of disadvantaged usually expressed interest in medicine, whilst those in applicants, with 4.3% applicants from a disadvantaged Year 9 have been nominated by their teachers as poten- background compared to an average of 10.9% for tially having the aptitude to study medicine or dentistry. other subjects [3]. It appears that structural inequal- The Year 12 days are therefore wholly focused on medi- ities exist before engagement with the admissions cine (with separate days for dentistry). The Year 9 days process. have a morning or afternoon on medicine and the other Such an imbalance in applications cannot therefore be half of the day on dentistry. This research focused only addressed purely through selection processes and the con- on medicine. sideration of students’ backgrounds during selection [14]. Recruitment of Widening Participation schools and Earlier intervention to improve the equity of applications students is prioritised for MaD days; however, school en- is necessary, as evidence suggests SES impacts education gagement varies, meaning representation of particular from an early age [15]and by 14–16 years old academic- socioeconomic profiles cannot be assured. Five criteria ally able, disadvantaged students see medical school as for Widening Participation status are used: home post- ‘culturally alien’ [16]. Medical schools should therefore ex- code, studying at a school which is part of an established plore what can be done to encourage able students from Widening Participation programme, receipt of free all backgrounds to consider medical careers. school meals, being in local authority care and whether Martin et al. BMC Medical Education (2018) 18:117 Page 3 of 13 either parent has completed higher education. These cri- medicine. The primary goal of this was to prime partici- teria reflect the types of contextual data – community, pants to focus on the topic, but the questionnaires were school and individual – identified in the Selecting for quickly reviewed by researchers before the card sorting Excellence report [4]. tasks in case any substantially different factors had been identified. Questionnaires also recorded participants’ Methods names to link to Widening Participation data collected Pilot study during MaD day registration. In order to develop and sense-check materials for the Participants were divided into four facilitated groups first of the Year 12 sessions, a pilot session was carried of nine. Each group sorted the deterrents along a scale out with current medical students (n = 12) and junior of importance, discussed decisions as a group and re- doctors (n = 2). This was conducted by authors BB and moved cards felt to be irrelevant. Participants could add AC, before the appointment of other authors as student further deterrents to the set. interns. Some pilot session participants self-identified as being from Widening Participation backgrounds or Session 2 schools, but their Widening Participation status was not Session 2 aimed to understand the reasoning behind formally recorded. Session 1 deterrents, elaborate how they may be ad- Using a method based on the nominal group tech- dressed and where responsibility for those solutions may nique, with questions answered individually on paper lie – with the individual participant, the school, medical and then discussed with the group, participants were school or elsewhere. asked to consider what had attracted them to medicine, A pre-session priming questionnaire was again used to and what could have deterred them. They were asked to focus participants and to record their names. Data from focus on recall of their own experience. Responses were Session 1 were used to produce eight specific deterrent used to inform the materials used in the research statements, which were pinned to a board and used as sessions. the basis of discussion (Table 1). In group discussions participants were asked whether they agreed with the Research sessions deterrents listed. After 10 min, cards were added to the Research sessions were carried out on each of the six board to prompt suggestions of the agencies which MaD days – three with Year 9, three with Year 12. could deliver solutions. Audio-recording supplemented The project methodology was necessarily pragmatic to field notes and the pre-session questionnaire. fit within the existing MaD day timetable. Principles of action research were used, with the outputs of Session 3 each research session being fed back into subsequent Session 3 aimed to elaborate areas which the medical iterations [20]. school has greatest capacity to influence, rather than relying on the influence of schools, NHS Trusts or na- Year 12 sessions tional policy. It consisted of five concurrent focus groups Year 12 MaD days took place in November–December with 6–7 participants addressing three issues raised in 2015. Each research session was limited to approxi- Session 2 that were identified as within the purview of mately 40 min and took place following the MaD day ac- the university: the application process, work experience, tivities. Session 1 addressed the attractions and and course content. Groups discussed each question for deterrents to medicine and identified potential solutions. around 15–20 min. This fed into Session 2 which further elaborated solu- tions and their sources and provided the focus for Ses- sion 3. Year 9 sessions Year 9 sessions aimed to understand perceptions of Session 1 medicine held by younger, academically able students Session 1 was based around a card-sorting task to iden- and the factors influencing their aspirations. They were tify and prioritise deterrents to choosing medicine. The integrated into the half-day MaD activity as one of four deterrents identified in the pilot session were used as 20-min stations, meaning that time was more limited prompts to simplify the task and reduce pressure on par- than in the Year 12 MaD days. Sessions were repeated ticipants, but participants were encouraged to provide four times on each day with around 25 participants in commentary on those prompts and generate new each (meaning around 100 participants on each day). deterrents. Schoolteachers were present in and contributed to dis- A pre-session questionnaire contained free text ques- cussions. No pre-session questionnaires were used with tions about attractions and deterrents to studying Year 9 participants. Martin et al. BMC Medical Education (2018) 18:117 Page 4 of 13 Table 1 Mapped Session 2 prompts The second activity focused on sorting 33 activities se- lected to reflect a range of medical specialties (eg ‘Pre- Prompt Category based upon scribing medicines to people’, ‘Organising the delivery of I don’t know enough the application Application process process healthcare in a region’) into ‘Doctor’ and ‘Not a doctor’ headings. Once participants as a group had agreed the It’s competitive: I don’t want to waste Application process a UCAS choice distribution of cards across these categories, debriefing I don’t know how to get work experience Application process explained that every activity was potentially part of medicine. I think there are problems in the NHS Careers and the future is uncertain Participants were then asked to indicate activities that most appealed to them by fixing adhesive dots to the I might find the course too difficult Course content cards. They could add two dots to a single activity, select I don’t know enough about the course: Course content I may change my mind two activities, or use one or neither of the dots. Finally, the question from the beginning of the session I don’t know how I will pay for the course Finance was repeated, and participants again asked to sort them- I may not fit in Social selves along the ‘Definitely not’–‘Definitely’ scale and the number at each position recorded. The findings from Session 1 directly informed the revi- Data were recorded through field notes, photographs sion of the approach used in both Sessions 2 and 3. of sorted cards, and the cards complete with adhesive Interactive group tasks were used to facilitate discussion. dots which were returned to the researchers. Session 1 Data analysis The first session sought to establish whether participants Analysis was adapted to the data collected in each ses- were considering medicine as a career and their reasons sion. Qualitative data, captured through written re- for this. Participants were asked ‘Would you like to be a sponses, audio recordings and field notes, were analysed doctor?’, ‘Can you see yourself as a doctor?’ and ‘Can you by content analysis – identifying and applying summary see yourself as a medical student?’ and asked to sort codes to statements. Data were summarised by BB, with themselves along a physical ‘scale’ by standing beside the coding, interpretation and application to subsequent ses- response card which best described their feeling: ‘Defin- sions discussed and agreed by all authors by email and itely not’, ‘Probably not’, ‘Maybe’ and ‘Definitely’. This in face-to-face meetings between sessions. Illustrative placement was used to prompt discussion and not re- quotes are given in the results where appropriate. corded. Students anonymously wrote down their reasons Quantitative data were recorded as the ordinal place- for their initial position and if their response differed be- ment of items in sorting tasks, and frequencies of re- tween questions they were asked to explain why. Groups sponses in group activities. were facilitated by pairs of medical student researchers (AM, GW, BJB, NW), with the other pair and BB ob- Ethical approval serving and taking notes. This study was approved by the Newcastle University Faculty of Medical Sciences Research Ethics Committee Session 2 and 3 (Reference: 00906/2015). All participants and parents Session 2 elaborated the identification of limited know- were sent an information sheet and consent form for ledge among participants and investigated whether a participation and audio recording. Year 12 students, be- short exercise could change views and aspirations. This ing over 16 years old, could provide written assent with- format proved useful and was retained for Session 3. out parental agreement. Students for whom consent or The session began with the same ‘Do you want to be a assent was not provided did not take part in the research doctor?’ question as Session 1. This time the number of sessions. participants at each ‘scale’ point was recorded. Two new activities then established students’ understanding of Results medical roles. In the first, a set of cards printed with Year 12 sessions: Results nine diverse medical job titles (eg ‘paediatrician’, ‘forensic Participants pathologist’) and nine non-medical titles (eg ‘nurse’, One hundred and twenty two of 164 (74%) attendees at ‘osteopath’) were distributed among the group, who were the three MaD days participated in the research. 84 asked to place them on a whiteboard under headings (74%) participants who provided demographic data were ‘Doctor’ and ‘Not a Doctor’. These were then reviewed female and 29 were male. The sexes of those who as a group, followed by a debrief where researchers ex- attended but did not take part in the research are not plained each job. known, but of those registered for the MaD day (not all Martin et al. BMC Medical Education (2018) 18:117 Page 5 of 13 of whom attended), 72% were female (n = 138). Those ‘political context’ included perceptions of medical ca- who took part met slightly more Widening Participation reers arising from a bigger picture, including media rep- criteria than those who were registered but did not take resentations and the societal image of medicine. part (a mean of 1.6 compared to 1.4). Other categories were less clearly linked to time, in Table 2 summarises the participants with the number that they could have relevance in the short and longer of Widening Participation criteria reported to the Fac- term. ‘Social background’ deterrents centred on com- ulty of Medical Sciences. Of the 113 (92.6%) participants parison with perceived stereotypes and concerns about for whom Widening Participation data were available, fitting in at medical school and disparity between the 95% met at least one of the five Widening Participation students’ social background and the social and class sta- criteria and 46% met more than one. A challenge of con- tus they felt doctors represent. References to knowledge ducting studies such as this during an outreach gaps arising from a lack of knowledgeable support from programme is demonstrated by the fact that just 10% of school and family were common across all codes. participants in Session 3 had > 1 Widening Participation The ranking of each deterrent’s priority was noted, criteria, meaning the results of this session need to be and those which were rated as being within the top five treated with caution. priority deterrents by any of the groups are summarised in Table 3. Those that were not agreed as priorities by Session 1 groups were still relevant to individual participants. Deterrents were coded into eight categories reflecting These included negative experiences of hospitals, lack of distinct areas of concern, supplemented by free text encouragement to apply for medicine and concerns comments on the questionnaire (see Table 3). Field notes about coping with unwell people. provided context and clarification on how deterrents Additional deterrents added by respondents included were interpreted. Coding was deliberately broad to sim- the availability and attraction of other careers and per- plify the deterrents into categories that would be mean- ceived over-emphasis on academic qualities over per- ingful to subsequent participants. Most focused on sonal ones. There was also reference to teachers process and context. doubting that students would get the necessary A-level Deterrents coded as ‘anticipation of the application grades for admission, meaning that it would not be process’ related to challenges which would arise before worthwhile applying. It may be that such predictions are entering medical school. Some ostensibly reflected stu- accurate, but the fact it is a substantive barrier indicates dents’ perceptions of their own ability (for example in that predictions can have material impact on student relation to required grades), but these were generally decisions. discussed in terms of the competitiveness of the process Session 1 confirmed that the deterrents identified by and whether an application to medicine represented a current medical students in pilot work were relevant to ‘good use’ of limited application choices, so focused on Year 12 students. process rather than aptitude. Deterrents relating to ‘concerns about the course’ in- Session 2 and 3 cluded uncertainty and apprehension about the course Free text responses to the questionnaire and the anno- difficulty and duration. Concerns around ‘financial cost’ tated boards in Session 2 were reviewed to identify com- – course fees and living costs across a course longer mon solutions. These represented the eight areas than most degrees – also arose. Those arising from brought forward from Session 1 with emphases on the Table 2 Numbers of participants and those meeting Widening Participation criteria at each Year 12 session Number attending Number taking part in Frequency (and % of session sample) of each of n with Widening Participation > 1 MaD day research (%) five Widening Participation criteria among (% of sample) respondents Postcode School Free School Care Parents Meals Session 44 36 (82%) 25 (69%) 17 10 (28%) 1 26 28 (77%) 1 (47%) (3%) (72%) Session 60 46 (77%) 29 (63%) 7 4 (9%) 0 23 24 (52%) 2 (15%) (50%) Session 60 40 (67%) 15 (38%) 7 3 (8%) 0 19 4 (10%) 3 (18%) (48%) Total 164 122 (74%) 69 (57%) 31 17 (14%) 1 68 56 (46%) (25%) (1%) (56%) Including participants who did not provide details to link to Widening Participation indices (Session 1 = 3 students, Session 2 = 6 students) Martin et al. BMC Medical Education (2018) 18:117 Page 6 of 13 Table 3 High priority deterrents identified in Year 12 Session 1 “None of my family have ever been to [university] … and my sixth form is really small…so I wouldn’t know Deterrent (number of groups ranking Category of deterrent deterrent in top five) where to start”. I don’t think I’ll get in (4) Anticipation of application Student awareness of pre-application aptitude tests process was poor, with uncertainty about what the tests involved, I might not get the grades (4) Anticipation of application cost (indeed, that there are fees and a bursary system), process that they are time-limited and that there are rules on re- I think there are problems in Political context sitting. For some, the MaD day was the first time they the NHS (3) had heard of the UKCAT. Medical students are from a Social background Some students expressed uncertainty about how to different background to me prepare an application and what to include. They identi- and I won’t fit in (3) fied a need to ‘stand out’, indicating awareness of the Having to do the UKCAT (2) Anticipation of application competitiveness of the process. process Websites were the primary route to information on Studying medicine is Financial cost expensive (2) the application process identified in Session 3. Some par- ticipants took specific, targeted approaches such as Five years is a long course (1) Concerns about course searching directly for a medical school or navigating Having to have an interview Anticipation of application from the university front page. Others started more to get in (1) process broadly, such as the national university applications I don’t know if I could be a Social background doctor (1) website. None were aware of other national online re- sources such as those on the Medical Schools Council I don’t know how I will pay Financial cost for the course (1) website. Just two participants mentioned the medical school’s social media presence. Students felt that out- I may not like the subject (1) Concerns about course reach events would benefit from a take-home, hard-copy I might find the course difficult (1) Concerns about course resource providing key facts. My family don’t know how Social background Students felt that work experience would be valuable to support me in applying (1) for them but were unclear about the role it plays in ad- My school don’t have anyone Social background missions decisions and how to access it. Few in both who can give me advice about applying (1) Session 2 and 3 had explored it in detail. This was felt to Negative stories about doctors Political context be a specific area of inequality, with some students able or medicine in the news (1) to arrange work experience through family and friends I don’t know how to get work Anticipation of application and some schools providing support. There were also experience (1) process barriers in the way Trusts offer and arrange work The number in brackets indicates the number of groups (out of 4) that ranked experience. the deterrent as among their ‘top five’, meaning that those at the top indicate “My local trust doesn’t really offer work experience, but more consensus [other trust] does, but they preserve it for people in the application process, work experience, knowledge of the area. It would be helpful if they worked together”. course, finance, and long-term prospects. Session 3 fo- Students’ age was a perceived barrier to being cused on the application process, work experience and trusted in a clinical environment by staff who did not course content. know the students; hospital and general practice (GP) policies echo this concern [2]. Application process and work experience Respondents had a limited view of relevant work While Widening Participation status could not be linked experience, with few identifying that volunteering in to individual responses, many students associated others’ non-medical settings could be relevant experience. social background with advantage in terms of school Many identified ‘work experience’ exclusively with a support and knowledge in the application process. specific, timetabled period arranged by their school “We don’t have careers advice so we’ve got to do every- and had not considered gaining experience outside thing ourselves. Teachers do help but they don’t know that. about everything”. “People who go to private schools will be schooled in Course content how to answer questions at interviews”. Participants felt they did not have a good understand- This perception was linked to their reported confi- ing of what the course involves. Uncertainties about dence in engaging with the process, and it seemed some the academic challenges of Higher Education and the felt that the challenges were overwhelming. change in learning style were common. Martin et al. BMC Medical Education (2018) 18:117 Page 7 of 13 “You’re used to having a teacher there all the time so Some students felt that the pressures of A-level study it’s different when you come to [university], they’re not go- limited their time for attending events and that outreach ing to be there”. visits to their school may be more time-efficient. Stu- There were also questions about student life and ad- dents felt sessions could provide opportunities to prac- justment to university, e.g. finding accommodation. This tice interviews or multiple mini interviews. social aspect was another area where a lack of access to Several participants identified a potential role for the first-hand knowledge from parents, siblings or friends medical school in arranging work experience by acting may add to uncertainty. as an intermediary in identifying and facilitating access The opportunities provided by MaD days to speak to to work experience placements. medical students were valued, compared to open days held by more senior staff. First-hand accounts, especially Summary of year 12 sessions from those with similar backgrounds, would be helpful. The Year 12 sessions identified and elaborated informa- tion needs among prospective applicants. These included Finance short-term considerations such as gaining work experi- Students expressed uncertainty about student loans, ence, details of the application process and finance, fees, repayments and the availability of support. They through information about course content and being a expressed interest in information on financial man- student, to longer term questions about medical careers. agement over a long university course, and again felt These issues were exacerbated for participants who felt that first-hand accounts from current or recent med- their schools were isolating for medicine applicants, and ical students would provide valuable insight. staff less knowledgeable and supportive. Careers Year 9 sessions: Results While many of the concerns surrounded applying to Year 9 sessions were repeated four times on each day medical school, longer term views about medicine as a with around 25 participants in each (meaning around career were also relevant. Medicine was perceived as dif- 100 participants on each day). No personal details were ferent to other courses and careers. obtained from these participants. The approximate gen- “I think it should be shown more as a vocation rather der distribution was 58% female (n = 170). Full Widening than just any old career path, it requires more than just Participation criteria for these participants were not turning up”. available, but of free school meals, being in care, or hav- Topics of work-life balance and stress were raised ing parents who did not complete higher education, 134 alongside recognition of the intrinsic rewards of working met one criterion, 22 met two, and 2 met all three. in medicine. There was, surprisingly, a perception of medicine as a ‘narrow’ career with few options – some- Session 1 thing that was explored further in the Year 9 sessions. Participants’ positions changed between the three ques- Participants also demonstrated a degree of political tions (‘Would you like to be a doctor?’, ‘Can you see awareness about current issues within the NHS which yourself as a doctor?’ and ‘Can you see yourself as a translated into concerns about longer-term prospects. medical student?’), indicating a difference in interest, perceived capability, and understanding of medical ca- Participant-proposed solutions reers. We cannot rule out that some moved because they Lack of information was the root of most deterrents. felt they were expected to, but most could articulate rea- There was a strong feeling that hearing from first and sons for changing their position, suggesting credibility of second year medical students would best help under- responses. standing the application process, while older students, Some in the ‘Definitely not’ or ‘Probably not’ groups junior doctors and faculty could best explain the course were simply uninterested in medicine. However, others and career options. referred to specific deterrents such as squeamishness The idea of peer support for applicants was raised. around blood and ‘gore’, and not wanting to have the ‘life Some participants lacked school peers applying for and death’ responsibility involved in medicine. These re- medicine and stated that informal peer contacts made sponses indicate how medicine is perceived at this age, on the MaD day were a useful source of support. This with a partial and limited view of what medicine may sense of peer community could be enabled by more encompass. visits to the medical school or a virtual community or Students responding ‘Maybe’ framed responses in forum for potential applicants. Third-party online for- terms of career choice – with some having interest in ums for applicants do exist, but these were not men- another career as well as medicine, and others feeling tioned by students. that it was too early to decide. Martin et al. BMC Medical Education (2018) 18:117 Page 8 of 13 “Not definitely sure what I want to be yet. Lot of pres- Table 6 gives the aggregate frequencies of participants sure choosing.” (Written response). at each point of the scale before and after the ses- Overall, Session 1 identified a lack of clear or detailed sions. Treating this as an ordinal scale, there was a knowledge about what a medical career may involve. clear shift in attitudes towards being more likely to The second and third sessions explored this further. consider medicine (p < 0.001, Mann Whitney U test, STATA Version 13.0). Session 2 and 3 Interestingly, accompanying teachers occasionally com- Identification of occupations mented on student categorisation of medical careers with Table 4 shows that groups correctly identified most of incorrect information. From informal discussions between the medical occupations as doctors, although forensic students and teachers during the sessions, it became evi- pathologist and microbiologist were identified only by a dent that some teachers were lacking in basic knowledge minority. However, few of the non-medical occupations about medical careers. For example, one incorrectly iden- were correctly identified. tified ‘podiatrist’ as a medical profession. Others provided Some occupations were unfamiliar (podiatrist, chiro- incorrect basic information on selection criteria and re- practor) and participants were largely guessing. However, quired A-levels, course content, course duration and ca- more familiar occupations (paramedic, midwife) were reers paths. Rather than directly correct teachers, still frequently misidentified as doctors. This reinforced researchers used this as an opportunity to open discussion the impression from Session 1 that students (and in around these areas in order to educate both students and some cases, teachers) do not have a clear idea of what teachers. This incidental finding reflects student concerns jobs medical school qualifies people to do. that some school staff are ill-equipped to provide accurate information. Identification of and interest in activities Table 5 summarises the number of groups which Summary of year 9 sessions identified each of the activities as part of a doctors’ In the Year 9 sessions we identified knowledge gaps around role and the extent to which each was of interest to the range of careers doctors can have and the types of work participants. While some of the more popular activ- activities these involve. We found that an interactive session ities may be expected from their presentation in the increased expressions of interest in medicine. We cannot media (eg ‘examining dead bodies’)there were also rule out the effect of peer influence and a conformity effect popular choices which may not be recognised as roles in some sessions, nor whether there was an effect of expec- in medicine (eg ‘developing new treatments or tations leading to changes in expressed views. However, drugs’). There was notable interest in empathic/com- groups appeared to interact naturally and we conclude that munication roles, but these were poorly identified as the observed effect is robust. roles performed by doctors. Many participants there- fore expressed interest in roles which they do not as- Discussion sociate with medicine, and so may not consider We have presented data collected from school students medicine as a career. who were at two different points in career decision-making: Finally, we considered the changes in stated expres- those who are just beginning to think about subject choices sions of interest in medicine, along the physical ordinal to enable higher education applications and those who are scale, between the beginning and end of the session. about to apply to university. Table 4 Frequency of correct identification of medical and non-medical occupations Medical occupations Session 2 Session 3 Non-medical occupations Session 2 Session 3 General practitioner 8 (100%) 8 (100%) Dentist 5 (62%) 4 (50%) Paediatrician 8 (100%) 8 (100%) Pharmacist 5 (62%) 3 (38%) Radiologist 8 (100%) 8 (100%) Optician 4 (50%) 3 (38%) Anaesthetist 7 (88%) 8 (100%) Psychologist 4 (50%) 5 (62%) Cardiologist 7 (88%) 7 (88%) Midwife 3 (38%) 2 (25%) Psychiatrist 7 (88%) 6 (75%) Chiropractor 2 (25%) 4 (50%) Surgeon 7 (88%) 8 (100%) Paramedic 2 (25%) 2 (25%) Forensic pathologist 2 (25%) 2 (25%) Physiotherapist 2 (25%) 3 (38%) Microbiologist 2 (25%) 2 (25%) Podiatrist 1 (12%) 1 (12%) Frequency indicates the number of 8 groups to correctly identify each response Martin et al. BMC Medical Education (2018) 18:117 Page 9 of 13 Table 5 Frequency of correct identification of activities and number of indications of interest a b No. groups correctly identifying activity Expressions of interest Activity Session 2 Session 3 Total Session 2 Session 3 Total Examining dead bodies from a crime scene 8 (100%) 7 (88%) 15 (94%) 30 (14.9%) 24 (12%) 54 (13.5%) Examining dead bodies to work out the 7 (88%) 7 (88%) 14 (88%) 15 (7.5%) 16 (8%) 31 (7.7%) cause of death Working with sports teams and athletes 1 (12%) 1 (12%) 2 (13%) 13 (6.5%) 17 (8.5%) 30 (7.5%) Looking after children and young people 6 (75%) 7 (88%) 13 (81%) 8 (4%) 21 (10.5%) 29 (7.2%) when they are in hospital Working in the Army/RAF/Navy 5 (62%) 7 (88%) 12 (75%) 12 (6%) 17 (8.5%) 29 (7.2%) Talking to people with mental health problems 5 (62%) 2 (25%) 7 (44%) 11 (5.5%) 16 (8%) 27 (6.7%) Helping people with cancer 8 (100%) 8 (100%) 16 (100%) 10 (5%) 16 (8%) 26 (6.5%) Performing operations 8 (100%) 8 (100%) 16 (100%) 18 (9%) 7 (3.5%) 25 (6.2%) Developing new treatments or drugs 5 (62%) 6 (75%) 11 (69%) 12 (6%) 13 (6.5%) 25 (6.2%) Looking after babies when they are born prematurely 4 (50%) 5 (62%) 9 (56%) 12 (6%) 7 (3.5%) 19 (4.7%) Researching new ways to try and cure diseases 5 (62%) 4 (50%) 9 (56%) 8 (4%) 7 (3.5%) 15 (3.7%) Diagnosing illness from X-rays and scans 8 (100%) 7 (88%) 15 (94%) 8 (4%) 2 (1%) 10 (2.5%) Talking to people about their everyday problems 1 (12%) 4 (50%) 5 (31%) 4 (2%) 6 (3%) 10 (2.5%) Putting people to sleep before an operation 8 (100%) 8 (100%) 16 (100%) 9 (4.5%) 0 9 (2.2%) Tracking the spread of diseases and trying 7 (88%) 7 (88%) 14 (88%) 2 (1%) 6 (3%) 8 (2%) to prevent spreading Teaching students 2 (25%) 5 (62%) 7 (44%) 2 (1%) 5 (2.5%) 7 (1.7%) Helping people overcome disability 2 (25%) 4 (50%) 6 (38%) 5 (2.5%) 2 (1%) 7 (1.7%) Caring for people at the end of their life 2 (25%) 2 (25%) 4 (25%) 5 (2.5%) 2 (1%) 7 (1.7%) Looking through a microscope to diagnose 8 (100%) 8 (100%) 16 (100%) 6 (3%) 0 6 (1.5%) diseases Finding out what people are allergic to 8 (100%) 7 (88%) 15 (94%) 2 (1%) 3 (1.5%) 5 (1.2%) Helping elderly people 1 (12%) 5 (62%) 6 (38%) 4 (2%) 1 (0.5%) 5 (1.2%) Delivering babies by performing an 7 (88%) 8 (100%) 15 (94%) 1 (0.5%) 3 (1.5%) 4 (1%) operation (C-section) Giving injections 7 (88%) 8 (100%) 15 (94%) 1 (0.5%) 3 (1.5%) 4 (1%) Performing CPR (resuscitation) to try 7 (88%) 7 (88%) 14 (88%) 1 (0.5%) 2 (1%) 3 (0.7%) and save someone’s life Helping pregnant women if they develop 2 (25%) 8 (100%) 10 (63%) 1 (0.5%) 2 (1%) 3 (0.7%) problems Prescribing medicines to people 5 (62%) 6 (75%) 11 (69%) 1 (0.5%) 1 (0.5%) 2 (0.5%) Sending people home from hospital 5 (62%) 5 (62%) 10 (63%) 0 1 (0.5%) 1 (0.2%) Organising the delivery of healthcare in a region 3 (38%) 1 (12%) 4 (25%) 0 0 0 Developing campaigns to improve the health 0 0 0 000 of everyone - stopping smoking, sexual health Working for a company to make sure people’s 0 0 0 000 workplaces are safe Total 201 200 401 The number of 8 groups per session, 16 in total, to correctly identify each response as part of doctors’ work Each participant was given two adhesive dots to allocate to the available activities to indicate which attracted them most. They could give two to the same activity, one each to separate activities, or allocate one or neither. The total is the sum of those allocated, which may be less than the number distributed to participants Our findings indicate several factors which under- Fundamentally, the challenges were rooted in mine young people’s awareness of medicine as a pos- knowledge gaps which may decrease or distort sible career and ways in which those gaps may be awareness of medicine as a possible career. Partici- addressed. pants in these workshops emphasised a need for Martin et al. BMC Medical Education (2018) 18:117 Page 10 of 13 Table 6 Combined frequencies of interest in medicine pre- and A short intervention with Year 9 students addressed post-intervention for Session 2 and 3 some career knowledge gaps and increased their consid- Definitely not Probably not Maybe Definitely eration of medicine but online materials and open days may reach a wider audience. Medical schools may focus Pre-intervention 15 (7%) 47 (23%) 103 (51%) 36 (18%) on outreach events for this age group with materials to Post-intervention 8 (4%) 25 (12%) 113 (56%) 55 (27%) explain the scope of a career in medicine. Includes data from both Session 2 (n = 101) and Session 3 (n = 100) Older students raised concerns about the political con- clear, practical information in distinct areas. These text of the NHS and careers in medicine. Notably, re- are detailed below. search sessions took place when a dispute around junior doctors’ contracts in the UK was gaining traction in na- tional media. Whilst we did not explore the detail The application process around these concerns, the British Medical Association Schools that do not regularly send students to medical has expressed concern that doctors who move abroad school may lack staff with the knowledge and time to following training may in future be required to repay prepare students for application. We noted incorrect in- training fees [22] and this may disproportionately deter formation being provided by some teachers on the appli- applicants from poorer backgrounds [23]. Medical cation process, length of the course and nature of the schools should recognise that students are socially and job. Ensuring that schoolteachers as well as students are politically aware and be prepared to address these engaged and informed may be key to reaching potential concerns. applicants. Many Widening Participation students have limited Work experience personal contacts who have studied in Higher Education Students were unclear about the role of work experi- or the medical field or attend schools with limited ex- ence, what experience was useful and how to access it, perience of supporting medical school applications. In- particularly when they had no medical family members. formation sources exist on preparing an application for Although medical schools recognise that work experi- medicine and entry examinations such as the UKCAT, ence can be difficult to come by, experience of clinical but students were not aware of these. Medical schools environments may help students make better decisions could clearly signpost students to this information or and medical schools could take a more active role in this provide direct support through outreach. process. Medical schools should also more clearly em- phasise that non-clinical experience of working with Understanding medicine and medical careers people is relevant and useful. There were also barriers in For younger students, the main knowledge gap related the way NHS organisations offer and arrange work ex- to the nature of medicine and breadth of medical ca- perience, therefore universities may work with NHS or- reers, meaning that students may have a limited view of ganisations to facilitate and promote work experience what medicine involves and the range of career options options. available within the profession. Students appeared to recognise diagnostic and procedural activities in medi- Course content, university life and finance cine but did not identify other activities including re- Students were uncertain about the academic chal- search, training, service development, public health or lenges of Higher Education, the change in learning the spectrum of patient groups. This may contribute to style required and social issues such as accommoda- perceptions that medicine is a narrow career. tion and adjusting to university life. This was particu- These early perceptions of what a career in medi- larly pertinent where students had few relatives and cine involves could also have impact on the future contacts to approach. Medical schools could provide workforce. For example, ‘talking to people with mental outreach sessions in association with existing univer- health problems’ wasidentifiedasamedicalrole by sity undergraduate advice services. This information less than half of the groups, yet this skill is a major may be delivered by early-stage medical students, part of many specialties, including GP, emergency which were a preferred source of information about medicine and psychiatry – all of which have problems the courseoversenioruniversitystaff. with recruitment and retention [21]. A lack of aware- Although students felt socioeconomic status influ- ness of the range of activities common in medicine, enced access to knowledgeable advice and support, combined with an over-emphasis on the ‘exciting’ participants did not express concerns about elitism in emergency elements of medicine in some media may medical school itself. This is in contrast to earlier deter applicants who are attracted to the more em- findings. A focus group of 14–16-year-old students pathetic aspects of medicine. found adverse stereotypes of medical students as Martin et al. BMC Medical Education (2018) 18:117 Page 11 of 13 elitist were off-putting [16], while an interview study online or face-to-face. For online resources, potential of mature medical students from working-class back- measures include search engine optimisation – ensuring grounds reported a predominant ‘identity conflict’ that appropriate web pages are returned to naïve stu- [24] due to perceived social elitism in medical dents’ searches (we found that one relevant blog was not schools. We found students focused more on struc- returned in the first pages of Google hits). A list of ‘fre- tural than personal factors. This could have been due quently asked questions’ prominently accessible from to methodology, which may have elicited a focus on medical schools’ course information and admissions web external deterrents rather than personal feelings. pages could address students’ practical concerns. Equally, the emphasis on perceived inequality of op- First-hand accounts have the potential to address un- portunity, rather than intergroup difference, may certainties about course content and careers. These mean that cultural barriers are not as rigid as earlier could take the form of written or video blogs from exist- authors have suggested. ing students and junior doctors, or talks and question Finally, the cost of medical training is a concern for and answer sessions in outreach and open day events. students and signposting to information about student The involvement of those from similar backgrounds was finance and NHS bursaries will be essential. Medical identified as particularly helpful by some participants – schools should note that NHS student bursaries are providing not just knowledge, but also role-modelling of changing [25] and anticipate how these changes may people who may not fit a socioeconomic stereotype. affect Widening Participation students. Finally, while open days and visits are helpful, these were also seen as time-consuming in a busy school term Social capital as a barrier with exam pressures ahead. As McLachlan noted [14], The knowledge gaps identified may be salient to all pro- outreach events may be more effective. Visits to schools spective applicants, regardless of their socioeconomic may reach those who may not volunteer for open days, background. However, they are likely to be more acute or be identified by teachers as being interested. If they for those without knowledgeable support at home or encourage interaction with peers, they may have value in school. supporting those who feel isolated. Students who may While we did not set out to consider barriers in theor- particularly benefit from these initiatives include youn- etical terms, our findings indicate the importance of ger students, those not yet considering medicine and knowledge from formal and informal social networks. those who are undecided. These may be seen as a form of social capital. Social cap- ital is a sociological concept which describes aspects of Limitations an individual’s social context, including information, The study has some limitations which we acknowledge which can be translated into human capital [26]. Effect- here. ively, it is a mechanism by which social power relations The study took place within a single medical school; are replicated. It has been widely considered in the con- therefore, findings may not be transferable to other loca- text of education [27], and found to be an influence on tions. However, the locality is geographically and socio- access to higher education among particular groups [28]. economically diverse and we have captured a range of views from many Widening Participation students. Modes of support The sample of participants was outside the control Deficits of social capital cannot necessarily be simply of the researchers. While there was very high partici- remediated, but recognising it is not just knowledge, but pation among those attending MaD days, the risk of support which may be lacking may help to shape selection bias nonetheless exists at two levels: stu- strategies. dents are selected by their schools to attend MaD It is not necessarily enough that information is avail- days, and school participation is itself subject to able; it must be accessible to and navigable by the target self-selection. The issues uncovered may therefore not population. This too can vary with the home and school be representative of students in other schools. Despite context of the student. Widening Participation students this, identifying problems faced by even a small pro- may need additional guidance on how to find and navi- portion of the theoretical population is still potentially gate resources if they do not have people around them useful. who can point them in the right direction. Younger Methodologically, the need to fit into the existing school students in particular may need school teachers format of the MaD days necessitated a pragmatic ap- or careers advisors to introduce the possibility of med- proach to data collection with a difficult-to-access ical career if it is not part of their home milieu. group. This involved compromises between the time We recommend that medical schools review how they available and the depth of data accessible. Rapid in- collate and signpost information, whether provided terpretation of findings was needed to feed into Martin et al. BMC Medical Education (2018) 18:117 Page 12 of 13 subsequent sessions. However, the consistency of Availability of data and materials The datasets used and/or analysed during the current study are available findings across different approaches gives them from the corresponding author on reasonable request. credibility. The research was conducted in large part by Authors’ contributions Conception of study: BB and GV. Development of workshop activities and current medical students working as student interns data collection: AM, BJB, GW, NW, AC, GV, BB. Data analysis: BB, with on the project (AM, BJB, GW and NW). While this interpretation by all other authors. Initial drafting of manuscript: BB and AM. contained a risk of bias in their having recent, and Critical revision of manuscript: BJB, GW, NW, AC, GV. Final approval of manuscript and acceptance of accountability for research: AM, BJB, GW, NW, successful, experience of applications and admissions AC, GV, BB. processes, their understanding was felt to be a strength in design and interpretation of the research. Authors’ information At the time of the study AM, BJB, GW and NW were medical students at All sessions were observed and data reviewed by a Newcastle University and AC an Academic Foundation Programme doctor non-clinician researcher (BB) which provided balance. on academic placement in the School of Medical Education. BB is Lecturer in No authors are currently involved in admissions Medical Education, and GV Senior Clinical Lecturer and Honorary Consultant, both in the School of Medical Education, Newcastle University. processes. Ethics approval and consent to participate This study was approved by the Newcastle University Faculty of Medical Conclusions Sciences Research Ethics Committee (Reference: 00906/2015). Written Students who may wish to consider medicine as a career informed consent to participate in the study was obtained from participants’ parents or legal guardians, or in the case of participants over 16 but under need reliable, structured information. A lack of awareness 18, written formal informed assent was accepted as meeting ethical of key areas of medical education and careers is wide- requirements. spread and those without access to relevant expertise at Consent for publication home or school have less opportunity to address this. As part of the process of informed consent, participants/parents or guardians Medical schools have a key role in widening participation were asked to provide consent for anonymised data to be included in and should facilitate access to reliable information publications. All who consented to participate gave this consent. through different modalities, including structured online Competing interests resources and through outreach delivered by a range of The authors declare that they have no competing interests. staff and students. The wide range of careers available within medicine Publisher’sNote should be emphasised in order to engage those who may Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. not have as much interest in more high-profile areas of medicine. Medical schools may also facilitate peer support Author details 1 2 for students who feel isolated in applying to medicine and Newcastle University, Newcastle-upon-Tyne, UK. School of Medical Education, Newcastle University, Ridley Building 1, Newcastle-upon-Tyne NE1 work with local NHS organisations to facilitate fair access 7RU, UK. to work experience opportunities. Future research should focus on evidence-based initiatives to inform and encour- Received: 15 June 2017 Accepted: 2 May 2018 age applicants to ensure that students from less advan- taged backgrounds are not excluded from medicine. References 1. Steven K, Dowell J, Jackson C, Guthrie B. Fair access to medicine? Abbreviations Retrospective analysis of UK medical schools application data 2009-2012 GP: General practice; MaD days: Medical and dentistry days; NHS: National using three measures of socioeconomic status. BMC Medical Education. Health Service; SES: Socio-economic status; UCAS: Universities and Colleges 2016;16(1):11. Admissions Service; UKCAT: United Kingdom Clinical Aptitude Test; 2. Milburn A: Fair Access to Professional Careers. London: Cabinet Office; 2012. WP: Widening participation https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/61090/IR_FairAccess_acc2.pdf. Accessed 23 May 2018. 3. Department for Business Innovation and Skills: Fulfilling our potential: teaching Acknowledgements excellence, social mobility and student choice: Her Majesty's Stationery Office; The authors would like to thank everyone who supported the research, 2015. https://assets.publishing.service.gov.uk/government/uploads/system/ particularly Dr. Paul Paes, Sub-Dean for MBBS Recruitment and Admissions; uploads/attachment_data/file/523420/bis-16-261-he-green-paper-fulfilling-our- Dr. Jo Matthan, Lecturer in the School of Medical Education; and Felicity Ste- potential-summary-of-responses.pdf. Accessed 23 May 2018. phenson, Student Recruitment Officer in the Faculty of Medical Sciences. The 4. Medical Schools Council. Selecting for Excellence Final Report. London; involvement of schools, teachers and the students who participated is also Medical Schools Council: 2014. https://www.medschools.ac.uk/media/1203/ recognised with gratitude. selecting-for-excellence-final-report.pdf. Accessed 23 May 2018. 5. Global Consensus for Social Accountability of Medical Schools: Consensus Funding document. 2010. http://healthsocialaccountability.org/. Accessed 23 May 2018. The project was supported by an Innovation Fund award from the 6. Castillo-Page L: Diversity in medical education: Facts & Figures 2012. Newcastle University Learning, Teaching and Student Experience Committee. Washington DC Association of American Medical Colleges; 2012. https:// This funding supported the employment of authors AM, BJB, GW and NW as members.aamc.org/eweb/upload/Diversity%20in%20Medical%20Education_ student interns in 2015–16. The funding committee had no role in the Facts%20and%20Figures%202012.pdf. Accessed 23 May 2018. design or execution of the study, analysis or interpretation of the results, 7. Behrendt L, Larkin S, Griew R, Kelly P: Review of higher education access reporting or development of this manuscript. and outcomes for aboriginal and Torres Strait islander people: final report. Martin et al. BMC Medical Education (2018) 18:117 Page 13 of 13 Canberra, ACT, Australia: Australian Government Department of Education and Training; 2012. https://docs.education.gov.au/system/files/doc/other/ heaccessandoutcomesforaboriginalandtorresstraitislanderfinalreport.pdf. Accessed 23 May 2018. 8. Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of first-year students in Canadian medical schools. CMAJ. 2002;166(8):1029–35. 9. Prideaux D, Roberts C, Eva K, Centeno A, McCrorie P, McManus C, Patterson F, Powis D, Tekian A, Wilkinson D. Assessment for selection for the health care professions and specialty training: consensus statement and recommendations from the Ottawa 2010 conference. Med Teach. 2011; 33(3):215–23. 10. Arulampalam W, Naylor R, Smith J. Doctor who? Who gets admission offers in UK medical schools. Coventry: University of Warwick; 2005. https:// warwick.ac.uk/fac/cross_fac/healthatwarwick/newsandevents/past_events/ seminar_series_20056/wiji.pdf. Accessed 23 May 2018. 11. Dowell J, Norbury M, Steven K, Guthrie B. Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work. BMC Med Educ. 2015;15(1):165. 12. Cooter R, Erdmann JB, Gonnella JS, Callahan CA, Hojat M, Xu G. Economic diversity in medical education. Eval Health Prof. 2004;27(3):252–64. 13. Houston M, Osborne M, Rimmer R. Private schooling and admission to medicine: a case study using matched samples and causal mediation analysis. BMC Med Educ. 2015;15:136. 14. McLachlan JC. Outreach is better than selection for increasing diversity. Med Educ. 2005;39:872–5. 15. Sacker A, Schoon I, Bartley M. Social inequality in educational achievement and psychosocial adjustment throughout childhood: magnitude and mechanisms. Soc Sci Med. 2002;55:863–80. 16. Greenhalgh T, Seyan K, Boynton P. “Not a university type”: focus group study of social class, ethnic and sex differences in school pupils’ perception about medical school. Br Med J. 2004;328:1541. 17. Kamali AW, Nicholson S, Wood DF. A model for widening access into medicine and dentistry: the SAMDA-BL project. Med Educ. 2005;39:918–25. 18. Cleland J. Taking context seriously: explaining widening access policy enactments in UK medical schools. Med Educ. 2015;49:25–35. 19. Powis D, Hamilton J, McManus I. Widening access by changing the criteria for selecting medical students. Teach Teach Educ. 2007;23:1235–45. 20. Kemmis S, Mctaggart R. The action research planner. 3rd ed. Victoria: Deakin University; 1988. 21. British Medical Association. Workload, recruitment, retention and morale: a BMA member briefing for the 2 May 2016 Special Representative Meeting. p. 2016. https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/ influence/key%20negotiations/doctors%20pay/bma-evidence-to-ddrb- sept2016-annex-srm-2016-workforce-briefing.pdf. Accessed 23 May 2018. 22. Jeremy Hunt unveils plan to fine doctors who move abroad after training. http:// www.independent.co.uk/news/uk/politics/jeremy-hunt-plans-to-fine-doctors- who-move-abroad-after-training-a7343531.html. Accessed 23 May 2018. 23. British Medical Association: Expansion of Undergraduate Medical Education [Response to DH consultation]. Compiled by Jethwa R; 2017. https://www. bma.org.uk/-/media/files/pdfs/collective%20voice/influence/ uk%20governments/bma-full-submission-expansion-of-undergraduate- medical-education-25-may-2017.pdf. Accessed 23 May 2018. 24. Mathers J, Parry J. Why are there so few working-class applicants to medical schools? Learning from the success stories. Med Educ. 2009;43:219–28. 25. Department of Health: NHS bursary reform (Policy paper). London: The Stationery Office; 2017. https://www.gov.uk/government/publications/nhs- bursary-reform/nhs-bursary-reform. Accessed 23 May 2018. 26. Coleman JS. Social Capital in the Creation of human capital. The American journal of sociology, Vol. 94, Supplement: Organizations and Institutions. Soc Econ Approach Analys Soc Struct. 1988;94:S95–S120. 27. Dika SL, Singh K. Applications of social Capital in Educational Literature: a critical synthesis. Rev Educ Res. 2002;72:31–60. 28. Gonzalez KP, Stoner C, Jovel JE. Examining the role of social Capital in Access to College for Latinas: toward a college opportunity framework. J Hisp High Educ. 2003;2:146–70. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Education Springer Journals

Widening interest, widening participation: factors influencing school students’ aspirations to study medicine

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Education; Medical Education; Theory of Medicine/Bioethics
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Abstract

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. Keywords: Widening participation, Selection, Medical careers, Widening access, Medical school admissions * Correspondence: bryan.burford@newcastle.ac.uk School of Medical Education, Newcastle University, Ridley Building 1, Newcastle-upon-Tyne NE1 7RU, UK Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Martin et al. BMC Medical Education (2018) 18:117 Page 2 of 13 Background Literature has considered how to encourage wider ap- The under-representation of students applying for plications, for example information outreach [17]. How- and studying medicine from less advantaged socio- ever, some admissions staff have concerns about the economic backgrounds is an ongoing area of con- impact of Widening Participation on medical school cern. Across the countries of the UK, approximately reputation and view it negatively, ranging from a 75% of applicants to medicine have a parent in the box-ticking exercise to undesirable social engineering highest occupational socio-economic group, and [18]. Schools also neglect to evaluate the impact of Wid- 19.7–34.5% applicants live in the most affluent post- ening Participation activities [18]. This may in part ex- code decile versus 1.8–5.7% in the least affluent [1]. plain why there has been limited impact reported to The issue has been raised by governmental reports date [19]. into social mobility [2, 3] and the Medical Schools This project aimed to identify barriers or deterrents to Council, the corporate body for medical schools, is applying for medical school perceived by prospective examining how recruitment processes may address medical students and explore how those barriers may be this imbalance following its ‘Selecting for Excellence’ addressed, at what stage in school careers, and by which report [4]. This is not only a concern in the UK, but agency. has been described and prioritised internationally [5–9]. Research questions ‘Widening Participation’ (WP) is used to describe both The project was designed as exploratory research to the principle of increasing engagement in medical edu- consider the broad research questions ‘What barriers to cation and the schools and students who are targeted application to medical school are identified by school through related initiatives. Encouraging and facilitating students?’ and ‘What actions, and by which agencies, applications from all sections of society may benefit the may mitigate those barriers?’. The focus is on under- workforce by presenting a wider pool of applicants with- standing students’ perspectives, rather than evaluating out the need to reduce standards [10]. Doctors recruited existing interventions. from lower socio-economic status (SES) backgrounds are more likely to work in deprived areas [11] and pur- Context of the study sue under-supplied careers such as general practice [12]. This project was embedded within the timetable of an Medicine is typically regarded as a ‘selecting’ rather existing programme of Widening Participation activity than ‘recruiting’ subject, with more applicants than delivered by the Faculty of Medical Sciences at New- places. However, under-represented groups are also castle University – Medicine and Dentistry (MaD) under-represented in applications. Of those taking days – to access participants. However, the research the United Kingdom Clinical Aptitude Test was developed and conducted independently of the (UKCAT), required by most UK medical schools for organisers of the MaD days. school-leaver entry, 80% come from higher socioeco- MaD days, which are held in Newcastle University nomic groups [1]. Students from fee-paying private Medical School, offer didactic and practical sessions for schools are more likely to be accepted into medicine school students in Year 9 (age 13–14) and Year 12 (age independent of academic achievement [13]. Medicine, 16–17). Three days per year group take place each aca- dentistry and veterinary science are the university demic year. Those attending Year 12 MaD days have subjects with the lowest proportion of disadvantaged usually expressed interest in medicine, whilst those in applicants, with 4.3% applicants from a disadvantaged Year 9 have been nominated by their teachers as poten- background compared to an average of 10.9% for tially having the aptitude to study medicine or dentistry. other subjects [3]. It appears that structural inequal- The Year 12 days are therefore wholly focused on medi- ities exist before engagement with the admissions cine (with separate days for dentistry). The Year 9 days process. have a morning or afternoon on medicine and the other Such an imbalance in applications cannot therefore be half of the day on dentistry. This research focused only addressed purely through selection processes and the con- on medicine. sideration of students’ backgrounds during selection [14]. Recruitment of Widening Participation schools and Earlier intervention to improve the equity of applications students is prioritised for MaD days; however, school en- is necessary, as evidence suggests SES impacts education gagement varies, meaning representation of particular from an early age [15]and by 14–16 years old academic- socioeconomic profiles cannot be assured. Five criteria ally able, disadvantaged students see medical school as for Widening Participation status are used: home post- ‘culturally alien’ [16]. Medical schools should therefore ex- code, studying at a school which is part of an established plore what can be done to encourage able students from Widening Participation programme, receipt of free all backgrounds to consider medical careers. school meals, being in local authority care and whether Martin et al. BMC Medical Education (2018) 18:117 Page 3 of 13 either parent has completed higher education. These cri- medicine. The primary goal of this was to prime partici- teria reflect the types of contextual data – community, pants to focus on the topic, but the questionnaires were school and individual – identified in the Selecting for quickly reviewed by researchers before the card sorting Excellence report [4]. tasks in case any substantially different factors had been identified. Questionnaires also recorded participants’ Methods names to link to Widening Participation data collected Pilot study during MaD day registration. In order to develop and sense-check materials for the Participants were divided into four facilitated groups first of the Year 12 sessions, a pilot session was carried of nine. Each group sorted the deterrents along a scale out with current medical students (n = 12) and junior of importance, discussed decisions as a group and re- doctors (n = 2). This was conducted by authors BB and moved cards felt to be irrelevant. Participants could add AC, before the appointment of other authors as student further deterrents to the set. interns. Some pilot session participants self-identified as being from Widening Participation backgrounds or Session 2 schools, but their Widening Participation status was not Session 2 aimed to understand the reasoning behind formally recorded. Session 1 deterrents, elaborate how they may be ad- Using a method based on the nominal group tech- dressed and where responsibility for those solutions may nique, with questions answered individually on paper lie – with the individual participant, the school, medical and then discussed with the group, participants were school or elsewhere. asked to consider what had attracted them to medicine, A pre-session priming questionnaire was again used to and what could have deterred them. They were asked to focus participants and to record their names. Data from focus on recall of their own experience. Responses were Session 1 were used to produce eight specific deterrent used to inform the materials used in the research statements, which were pinned to a board and used as sessions. the basis of discussion (Table 1). In group discussions participants were asked whether they agreed with the Research sessions deterrents listed. After 10 min, cards were added to the Research sessions were carried out on each of the six board to prompt suggestions of the agencies which MaD days – three with Year 9, three with Year 12. could deliver solutions. Audio-recording supplemented The project methodology was necessarily pragmatic to field notes and the pre-session questionnaire. fit within the existing MaD day timetable. Principles of action research were used, with the outputs of Session 3 each research session being fed back into subsequent Session 3 aimed to elaborate areas which the medical iterations [20]. school has greatest capacity to influence, rather than relying on the influence of schools, NHS Trusts or na- Year 12 sessions tional policy. It consisted of five concurrent focus groups Year 12 MaD days took place in November–December with 6–7 participants addressing three issues raised in 2015. Each research session was limited to approxi- Session 2 that were identified as within the purview of mately 40 min and took place following the MaD day ac- the university: the application process, work experience, tivities. Session 1 addressed the attractions and and course content. Groups discussed each question for deterrents to medicine and identified potential solutions. around 15–20 min. This fed into Session 2 which further elaborated solu- tions and their sources and provided the focus for Ses- sion 3. Year 9 sessions Year 9 sessions aimed to understand perceptions of Session 1 medicine held by younger, academically able students Session 1 was based around a card-sorting task to iden- and the factors influencing their aspirations. They were tify and prioritise deterrents to choosing medicine. The integrated into the half-day MaD activity as one of four deterrents identified in the pilot session were used as 20-min stations, meaning that time was more limited prompts to simplify the task and reduce pressure on par- than in the Year 12 MaD days. Sessions were repeated ticipants, but participants were encouraged to provide four times on each day with around 25 participants in commentary on those prompts and generate new each (meaning around 100 participants on each day). deterrents. Schoolteachers were present in and contributed to dis- A pre-session questionnaire contained free text ques- cussions. No pre-session questionnaires were used with tions about attractions and deterrents to studying Year 9 participants. Martin et al. BMC Medical Education (2018) 18:117 Page 4 of 13 Table 1 Mapped Session 2 prompts The second activity focused on sorting 33 activities se- lected to reflect a range of medical specialties (eg ‘Pre- Prompt Category based upon scribing medicines to people’, ‘Organising the delivery of I don’t know enough the application Application process process healthcare in a region’) into ‘Doctor’ and ‘Not a doctor’ headings. Once participants as a group had agreed the It’s competitive: I don’t want to waste Application process a UCAS choice distribution of cards across these categories, debriefing I don’t know how to get work experience Application process explained that every activity was potentially part of medicine. I think there are problems in the NHS Careers and the future is uncertain Participants were then asked to indicate activities that most appealed to them by fixing adhesive dots to the I might find the course too difficult Course content cards. They could add two dots to a single activity, select I don’t know enough about the course: Course content I may change my mind two activities, or use one or neither of the dots. Finally, the question from the beginning of the session I don’t know how I will pay for the course Finance was repeated, and participants again asked to sort them- I may not fit in Social selves along the ‘Definitely not’–‘Definitely’ scale and the number at each position recorded. The findings from Session 1 directly informed the revi- Data were recorded through field notes, photographs sion of the approach used in both Sessions 2 and 3. of sorted cards, and the cards complete with adhesive Interactive group tasks were used to facilitate discussion. dots which were returned to the researchers. Session 1 Data analysis The first session sought to establish whether participants Analysis was adapted to the data collected in each ses- were considering medicine as a career and their reasons sion. Qualitative data, captured through written re- for this. Participants were asked ‘Would you like to be a sponses, audio recordings and field notes, were analysed doctor?’, ‘Can you see yourself as a doctor?’ and ‘Can you by content analysis – identifying and applying summary see yourself as a medical student?’ and asked to sort codes to statements. Data were summarised by BB, with themselves along a physical ‘scale’ by standing beside the coding, interpretation and application to subsequent ses- response card which best described their feeling: ‘Defin- sions discussed and agreed by all authors by email and itely not’, ‘Probably not’, ‘Maybe’ and ‘Definitely’. This in face-to-face meetings between sessions. Illustrative placement was used to prompt discussion and not re- quotes are given in the results where appropriate. corded. Students anonymously wrote down their reasons Quantitative data were recorded as the ordinal place- for their initial position and if their response differed be- ment of items in sorting tasks, and frequencies of re- tween questions they were asked to explain why. Groups sponses in group activities. were facilitated by pairs of medical student researchers (AM, GW, BJB, NW), with the other pair and BB ob- Ethical approval serving and taking notes. This study was approved by the Newcastle University Faculty of Medical Sciences Research Ethics Committee Session 2 and 3 (Reference: 00906/2015). All participants and parents Session 2 elaborated the identification of limited know- were sent an information sheet and consent form for ledge among participants and investigated whether a participation and audio recording. Year 12 students, be- short exercise could change views and aspirations. This ing over 16 years old, could provide written assent with- format proved useful and was retained for Session 3. out parental agreement. Students for whom consent or The session began with the same ‘Do you want to be a assent was not provided did not take part in the research doctor?’ question as Session 1. This time the number of sessions. participants at each ‘scale’ point was recorded. Two new activities then established students’ understanding of Results medical roles. In the first, a set of cards printed with Year 12 sessions: Results nine diverse medical job titles (eg ‘paediatrician’, ‘forensic Participants pathologist’) and nine non-medical titles (eg ‘nurse’, One hundred and twenty two of 164 (74%) attendees at ‘osteopath’) were distributed among the group, who were the three MaD days participated in the research. 84 asked to place them on a whiteboard under headings (74%) participants who provided demographic data were ‘Doctor’ and ‘Not a Doctor’. These were then reviewed female and 29 were male. The sexes of those who as a group, followed by a debrief where researchers ex- attended but did not take part in the research are not plained each job. known, but of those registered for the MaD day (not all Martin et al. BMC Medical Education (2018) 18:117 Page 5 of 13 of whom attended), 72% were female (n = 138). Those ‘political context’ included perceptions of medical ca- who took part met slightly more Widening Participation reers arising from a bigger picture, including media rep- criteria than those who were registered but did not take resentations and the societal image of medicine. part (a mean of 1.6 compared to 1.4). Other categories were less clearly linked to time, in Table 2 summarises the participants with the number that they could have relevance in the short and longer of Widening Participation criteria reported to the Fac- term. ‘Social background’ deterrents centred on com- ulty of Medical Sciences. Of the 113 (92.6%) participants parison with perceived stereotypes and concerns about for whom Widening Participation data were available, fitting in at medical school and disparity between the 95% met at least one of the five Widening Participation students’ social background and the social and class sta- criteria and 46% met more than one. A challenge of con- tus they felt doctors represent. References to knowledge ducting studies such as this during an outreach gaps arising from a lack of knowledgeable support from programme is demonstrated by the fact that just 10% of school and family were common across all codes. participants in Session 3 had > 1 Widening Participation The ranking of each deterrent’s priority was noted, criteria, meaning the results of this session need to be and those which were rated as being within the top five treated with caution. priority deterrents by any of the groups are summarised in Table 3. Those that were not agreed as priorities by Session 1 groups were still relevant to individual participants. Deterrents were coded into eight categories reflecting These included negative experiences of hospitals, lack of distinct areas of concern, supplemented by free text encouragement to apply for medicine and concerns comments on the questionnaire (see Table 3). Field notes about coping with unwell people. provided context and clarification on how deterrents Additional deterrents added by respondents included were interpreted. Coding was deliberately broad to sim- the availability and attraction of other careers and per- plify the deterrents into categories that would be mean- ceived over-emphasis on academic qualities over per- ingful to subsequent participants. Most focused on sonal ones. There was also reference to teachers process and context. doubting that students would get the necessary A-level Deterrents coded as ‘anticipation of the application grades for admission, meaning that it would not be process’ related to challenges which would arise before worthwhile applying. It may be that such predictions are entering medical school. Some ostensibly reflected stu- accurate, but the fact it is a substantive barrier indicates dents’ perceptions of their own ability (for example in that predictions can have material impact on student relation to required grades), but these were generally decisions. discussed in terms of the competitiveness of the process Session 1 confirmed that the deterrents identified by and whether an application to medicine represented a current medical students in pilot work were relevant to ‘good use’ of limited application choices, so focused on Year 12 students. process rather than aptitude. Deterrents relating to ‘concerns about the course’ in- Session 2 and 3 cluded uncertainty and apprehension about the course Free text responses to the questionnaire and the anno- difficulty and duration. Concerns around ‘financial cost’ tated boards in Session 2 were reviewed to identify com- – course fees and living costs across a course longer mon solutions. These represented the eight areas than most degrees – also arose. Those arising from brought forward from Session 1 with emphases on the Table 2 Numbers of participants and those meeting Widening Participation criteria at each Year 12 session Number attending Number taking part in Frequency (and % of session sample) of each of n with Widening Participation > 1 MaD day research (%) five Widening Participation criteria among (% of sample) respondents Postcode School Free School Care Parents Meals Session 44 36 (82%) 25 (69%) 17 10 (28%) 1 26 28 (77%) 1 (47%) (3%) (72%) Session 60 46 (77%) 29 (63%) 7 4 (9%) 0 23 24 (52%) 2 (15%) (50%) Session 60 40 (67%) 15 (38%) 7 3 (8%) 0 19 4 (10%) 3 (18%) (48%) Total 164 122 (74%) 69 (57%) 31 17 (14%) 1 68 56 (46%) (25%) (1%) (56%) Including participants who did not provide details to link to Widening Participation indices (Session 1 = 3 students, Session 2 = 6 students) Martin et al. BMC Medical Education (2018) 18:117 Page 6 of 13 Table 3 High priority deterrents identified in Year 12 Session 1 “None of my family have ever been to [university] … and my sixth form is really small…so I wouldn’t know Deterrent (number of groups ranking Category of deterrent deterrent in top five) where to start”. I don’t think I’ll get in (4) Anticipation of application Student awareness of pre-application aptitude tests process was poor, with uncertainty about what the tests involved, I might not get the grades (4) Anticipation of application cost (indeed, that there are fees and a bursary system), process that they are time-limited and that there are rules on re- I think there are problems in Political context sitting. For some, the MaD day was the first time they the NHS (3) had heard of the UKCAT. Medical students are from a Social background Some students expressed uncertainty about how to different background to me prepare an application and what to include. They identi- and I won’t fit in (3) fied a need to ‘stand out’, indicating awareness of the Having to do the UKCAT (2) Anticipation of application competitiveness of the process. process Websites were the primary route to information on Studying medicine is Financial cost expensive (2) the application process identified in Session 3. Some par- ticipants took specific, targeted approaches such as Five years is a long course (1) Concerns about course searching directly for a medical school or navigating Having to have an interview Anticipation of application from the university front page. Others started more to get in (1) process broadly, such as the national university applications I don’t know if I could be a Social background doctor (1) website. None were aware of other national online re- sources such as those on the Medical Schools Council I don’t know how I will pay Financial cost for the course (1) website. Just two participants mentioned the medical school’s social media presence. Students felt that out- I may not like the subject (1) Concerns about course reach events would benefit from a take-home, hard-copy I might find the course difficult (1) Concerns about course resource providing key facts. My family don’t know how Social background Students felt that work experience would be valuable to support me in applying (1) for them but were unclear about the role it plays in ad- My school don’t have anyone Social background missions decisions and how to access it. Few in both who can give me advice about applying (1) Session 2 and 3 had explored it in detail. This was felt to Negative stories about doctors Political context be a specific area of inequality, with some students able or medicine in the news (1) to arrange work experience through family and friends I don’t know how to get work Anticipation of application and some schools providing support. There were also experience (1) process barriers in the way Trusts offer and arrange work The number in brackets indicates the number of groups (out of 4) that ranked experience. the deterrent as among their ‘top five’, meaning that those at the top indicate “My local trust doesn’t really offer work experience, but more consensus [other trust] does, but they preserve it for people in the application process, work experience, knowledge of the area. It would be helpful if they worked together”. course, finance, and long-term prospects. Session 3 fo- Students’ age was a perceived barrier to being cused on the application process, work experience and trusted in a clinical environment by staff who did not course content. know the students; hospital and general practice (GP) policies echo this concern [2]. Application process and work experience Respondents had a limited view of relevant work While Widening Participation status could not be linked experience, with few identifying that volunteering in to individual responses, many students associated others’ non-medical settings could be relevant experience. social background with advantage in terms of school Many identified ‘work experience’ exclusively with a support and knowledge in the application process. specific, timetabled period arranged by their school “We don’t have careers advice so we’ve got to do every- and had not considered gaining experience outside thing ourselves. Teachers do help but they don’t know that. about everything”. “People who go to private schools will be schooled in Course content how to answer questions at interviews”. Participants felt they did not have a good understand- This perception was linked to their reported confi- ing of what the course involves. Uncertainties about dence in engaging with the process, and it seemed some the academic challenges of Higher Education and the felt that the challenges were overwhelming. change in learning style were common. Martin et al. BMC Medical Education (2018) 18:117 Page 7 of 13 “You’re used to having a teacher there all the time so Some students felt that the pressures of A-level study it’s different when you come to [university], they’re not go- limited their time for attending events and that outreach ing to be there”. visits to their school may be more time-efficient. Stu- There were also questions about student life and ad- dents felt sessions could provide opportunities to prac- justment to university, e.g. finding accommodation. This tice interviews or multiple mini interviews. social aspect was another area where a lack of access to Several participants identified a potential role for the first-hand knowledge from parents, siblings or friends medical school in arranging work experience by acting may add to uncertainty. as an intermediary in identifying and facilitating access The opportunities provided by MaD days to speak to to work experience placements. medical students were valued, compared to open days held by more senior staff. First-hand accounts, especially Summary of year 12 sessions from those with similar backgrounds, would be helpful. The Year 12 sessions identified and elaborated informa- tion needs among prospective applicants. These included Finance short-term considerations such as gaining work experi- Students expressed uncertainty about student loans, ence, details of the application process and finance, fees, repayments and the availability of support. They through information about course content and being a expressed interest in information on financial man- student, to longer term questions about medical careers. agement over a long university course, and again felt These issues were exacerbated for participants who felt that first-hand accounts from current or recent med- their schools were isolating for medicine applicants, and ical students would provide valuable insight. staff less knowledgeable and supportive. Careers Year 9 sessions: Results While many of the concerns surrounded applying to Year 9 sessions were repeated four times on each day medical school, longer term views about medicine as a with around 25 participants in each (meaning around career were also relevant. Medicine was perceived as dif- 100 participants on each day). No personal details were ferent to other courses and careers. obtained from these participants. The approximate gen- “I think it should be shown more as a vocation rather der distribution was 58% female (n = 170). Full Widening than just any old career path, it requires more than just Participation criteria for these participants were not turning up”. available, but of free school meals, being in care, or hav- Topics of work-life balance and stress were raised ing parents who did not complete higher education, 134 alongside recognition of the intrinsic rewards of working met one criterion, 22 met two, and 2 met all three. in medicine. There was, surprisingly, a perception of medicine as a ‘narrow’ career with few options – some- Session 1 thing that was explored further in the Year 9 sessions. Participants’ positions changed between the three ques- Participants also demonstrated a degree of political tions (‘Would you like to be a doctor?’, ‘Can you see awareness about current issues within the NHS which yourself as a doctor?’ and ‘Can you see yourself as a translated into concerns about longer-term prospects. medical student?’), indicating a difference in interest, perceived capability, and understanding of medical ca- Participant-proposed solutions reers. We cannot rule out that some moved because they Lack of information was the root of most deterrents. felt they were expected to, but most could articulate rea- There was a strong feeling that hearing from first and sons for changing their position, suggesting credibility of second year medical students would best help under- responses. standing the application process, while older students, Some in the ‘Definitely not’ or ‘Probably not’ groups junior doctors and faculty could best explain the course were simply uninterested in medicine. However, others and career options. referred to specific deterrents such as squeamishness The idea of peer support for applicants was raised. around blood and ‘gore’, and not wanting to have the ‘life Some participants lacked school peers applying for and death’ responsibility involved in medicine. These re- medicine and stated that informal peer contacts made sponses indicate how medicine is perceived at this age, on the MaD day were a useful source of support. This with a partial and limited view of what medicine may sense of peer community could be enabled by more encompass. visits to the medical school or a virtual community or Students responding ‘Maybe’ framed responses in forum for potential applicants. Third-party online for- terms of career choice – with some having interest in ums for applicants do exist, but these were not men- another career as well as medicine, and others feeling tioned by students. that it was too early to decide. Martin et al. BMC Medical Education (2018) 18:117 Page 8 of 13 “Not definitely sure what I want to be yet. Lot of pres- Table 6 gives the aggregate frequencies of participants sure choosing.” (Written response). at each point of the scale before and after the ses- Overall, Session 1 identified a lack of clear or detailed sions. Treating this as an ordinal scale, there was a knowledge about what a medical career may involve. clear shift in attitudes towards being more likely to The second and third sessions explored this further. consider medicine (p < 0.001, Mann Whitney U test, STATA Version 13.0). Session 2 and 3 Interestingly, accompanying teachers occasionally com- Identification of occupations mented on student categorisation of medical careers with Table 4 shows that groups correctly identified most of incorrect information. From informal discussions between the medical occupations as doctors, although forensic students and teachers during the sessions, it became evi- pathologist and microbiologist were identified only by a dent that some teachers were lacking in basic knowledge minority. However, few of the non-medical occupations about medical careers. For example, one incorrectly iden- were correctly identified. tified ‘podiatrist’ as a medical profession. Others provided Some occupations were unfamiliar (podiatrist, chiro- incorrect basic information on selection criteria and re- practor) and participants were largely guessing. However, quired A-levels, course content, course duration and ca- more familiar occupations (paramedic, midwife) were reers paths. Rather than directly correct teachers, still frequently misidentified as doctors. This reinforced researchers used this as an opportunity to open discussion the impression from Session 1 that students (and in around these areas in order to educate both students and some cases, teachers) do not have a clear idea of what teachers. This incidental finding reflects student concerns jobs medical school qualifies people to do. that some school staff are ill-equipped to provide accurate information. Identification of and interest in activities Table 5 summarises the number of groups which Summary of year 9 sessions identified each of the activities as part of a doctors’ In the Year 9 sessions we identified knowledge gaps around role and the extent to which each was of interest to the range of careers doctors can have and the types of work participants. While some of the more popular activ- activities these involve. We found that an interactive session ities may be expected from their presentation in the increased expressions of interest in medicine. We cannot media (eg ‘examining dead bodies’)there were also rule out the effect of peer influence and a conformity effect popular choices which may not be recognised as roles in some sessions, nor whether there was an effect of expec- in medicine (eg ‘developing new treatments or tations leading to changes in expressed views. However, drugs’). There was notable interest in empathic/com- groups appeared to interact naturally and we conclude that munication roles, but these were poorly identified as the observed effect is robust. roles performed by doctors. Many participants there- fore expressed interest in roles which they do not as- Discussion sociate with medicine, and so may not consider We have presented data collected from school students medicine as a career. who were at two different points in career decision-making: Finally, we considered the changes in stated expres- those who are just beginning to think about subject choices sions of interest in medicine, along the physical ordinal to enable higher education applications and those who are scale, between the beginning and end of the session. about to apply to university. Table 4 Frequency of correct identification of medical and non-medical occupations Medical occupations Session 2 Session 3 Non-medical occupations Session 2 Session 3 General practitioner 8 (100%) 8 (100%) Dentist 5 (62%) 4 (50%) Paediatrician 8 (100%) 8 (100%) Pharmacist 5 (62%) 3 (38%) Radiologist 8 (100%) 8 (100%) Optician 4 (50%) 3 (38%) Anaesthetist 7 (88%) 8 (100%) Psychologist 4 (50%) 5 (62%) Cardiologist 7 (88%) 7 (88%) Midwife 3 (38%) 2 (25%) Psychiatrist 7 (88%) 6 (75%) Chiropractor 2 (25%) 4 (50%) Surgeon 7 (88%) 8 (100%) Paramedic 2 (25%) 2 (25%) Forensic pathologist 2 (25%) 2 (25%) Physiotherapist 2 (25%) 3 (38%) Microbiologist 2 (25%) 2 (25%) Podiatrist 1 (12%) 1 (12%) Frequency indicates the number of 8 groups to correctly identify each response Martin et al. BMC Medical Education (2018) 18:117 Page 9 of 13 Table 5 Frequency of correct identification of activities and number of indications of interest a b No. groups correctly identifying activity Expressions of interest Activity Session 2 Session 3 Total Session 2 Session 3 Total Examining dead bodies from a crime scene 8 (100%) 7 (88%) 15 (94%) 30 (14.9%) 24 (12%) 54 (13.5%) Examining dead bodies to work out the 7 (88%) 7 (88%) 14 (88%) 15 (7.5%) 16 (8%) 31 (7.7%) cause of death Working with sports teams and athletes 1 (12%) 1 (12%) 2 (13%) 13 (6.5%) 17 (8.5%) 30 (7.5%) Looking after children and young people 6 (75%) 7 (88%) 13 (81%) 8 (4%) 21 (10.5%) 29 (7.2%) when they are in hospital Working in the Army/RAF/Navy 5 (62%) 7 (88%) 12 (75%) 12 (6%) 17 (8.5%) 29 (7.2%) Talking to people with mental health problems 5 (62%) 2 (25%) 7 (44%) 11 (5.5%) 16 (8%) 27 (6.7%) Helping people with cancer 8 (100%) 8 (100%) 16 (100%) 10 (5%) 16 (8%) 26 (6.5%) Performing operations 8 (100%) 8 (100%) 16 (100%) 18 (9%) 7 (3.5%) 25 (6.2%) Developing new treatments or drugs 5 (62%) 6 (75%) 11 (69%) 12 (6%) 13 (6.5%) 25 (6.2%) Looking after babies when they are born prematurely 4 (50%) 5 (62%) 9 (56%) 12 (6%) 7 (3.5%) 19 (4.7%) Researching new ways to try and cure diseases 5 (62%) 4 (50%) 9 (56%) 8 (4%) 7 (3.5%) 15 (3.7%) Diagnosing illness from X-rays and scans 8 (100%) 7 (88%) 15 (94%) 8 (4%) 2 (1%) 10 (2.5%) Talking to people about their everyday problems 1 (12%) 4 (50%) 5 (31%) 4 (2%) 6 (3%) 10 (2.5%) Putting people to sleep before an operation 8 (100%) 8 (100%) 16 (100%) 9 (4.5%) 0 9 (2.2%) Tracking the spread of diseases and trying 7 (88%) 7 (88%) 14 (88%) 2 (1%) 6 (3%) 8 (2%) to prevent spreading Teaching students 2 (25%) 5 (62%) 7 (44%) 2 (1%) 5 (2.5%) 7 (1.7%) Helping people overcome disability 2 (25%) 4 (50%) 6 (38%) 5 (2.5%) 2 (1%) 7 (1.7%) Caring for people at the end of their life 2 (25%) 2 (25%) 4 (25%) 5 (2.5%) 2 (1%) 7 (1.7%) Looking through a microscope to diagnose 8 (100%) 8 (100%) 16 (100%) 6 (3%) 0 6 (1.5%) diseases Finding out what people are allergic to 8 (100%) 7 (88%) 15 (94%) 2 (1%) 3 (1.5%) 5 (1.2%) Helping elderly people 1 (12%) 5 (62%) 6 (38%) 4 (2%) 1 (0.5%) 5 (1.2%) Delivering babies by performing an 7 (88%) 8 (100%) 15 (94%) 1 (0.5%) 3 (1.5%) 4 (1%) operation (C-section) Giving injections 7 (88%) 8 (100%) 15 (94%) 1 (0.5%) 3 (1.5%) 4 (1%) Performing CPR (resuscitation) to try 7 (88%) 7 (88%) 14 (88%) 1 (0.5%) 2 (1%) 3 (0.7%) and save someone’s life Helping pregnant women if they develop 2 (25%) 8 (100%) 10 (63%) 1 (0.5%) 2 (1%) 3 (0.7%) problems Prescribing medicines to people 5 (62%) 6 (75%) 11 (69%) 1 (0.5%) 1 (0.5%) 2 (0.5%) Sending people home from hospital 5 (62%) 5 (62%) 10 (63%) 0 1 (0.5%) 1 (0.2%) Organising the delivery of healthcare in a region 3 (38%) 1 (12%) 4 (25%) 0 0 0 Developing campaigns to improve the health 0 0 0 000 of everyone - stopping smoking, sexual health Working for a company to make sure people’s 0 0 0 000 workplaces are safe Total 201 200 401 The number of 8 groups per session, 16 in total, to correctly identify each response as part of doctors’ work Each participant was given two adhesive dots to allocate to the available activities to indicate which attracted them most. They could give two to the same activity, one each to separate activities, or allocate one or neither. The total is the sum of those allocated, which may be less than the number distributed to participants Our findings indicate several factors which under- Fundamentally, the challenges were rooted in mine young people’s awareness of medicine as a pos- knowledge gaps which may decrease or distort sible career and ways in which those gaps may be awareness of medicine as a possible career. Partici- addressed. pants in these workshops emphasised a need for Martin et al. BMC Medical Education (2018) 18:117 Page 10 of 13 Table 6 Combined frequencies of interest in medicine pre- and A short intervention with Year 9 students addressed post-intervention for Session 2 and 3 some career knowledge gaps and increased their consid- Definitely not Probably not Maybe Definitely eration of medicine but online materials and open days may reach a wider audience. Medical schools may focus Pre-intervention 15 (7%) 47 (23%) 103 (51%) 36 (18%) on outreach events for this age group with materials to Post-intervention 8 (4%) 25 (12%) 113 (56%) 55 (27%) explain the scope of a career in medicine. Includes data from both Session 2 (n = 101) and Session 3 (n = 100) Older students raised concerns about the political con- clear, practical information in distinct areas. These text of the NHS and careers in medicine. Notably, re- are detailed below. search sessions took place when a dispute around junior doctors’ contracts in the UK was gaining traction in na- tional media. Whilst we did not explore the detail The application process around these concerns, the British Medical Association Schools that do not regularly send students to medical has expressed concern that doctors who move abroad school may lack staff with the knowledge and time to following training may in future be required to repay prepare students for application. We noted incorrect in- training fees [22] and this may disproportionately deter formation being provided by some teachers on the appli- applicants from poorer backgrounds [23]. Medical cation process, length of the course and nature of the schools should recognise that students are socially and job. Ensuring that schoolteachers as well as students are politically aware and be prepared to address these engaged and informed may be key to reaching potential concerns. applicants. Many Widening Participation students have limited Work experience personal contacts who have studied in Higher Education Students were unclear about the role of work experi- or the medical field or attend schools with limited ex- ence, what experience was useful and how to access it, perience of supporting medical school applications. In- particularly when they had no medical family members. formation sources exist on preparing an application for Although medical schools recognise that work experi- medicine and entry examinations such as the UKCAT, ence can be difficult to come by, experience of clinical but students were not aware of these. Medical schools environments may help students make better decisions could clearly signpost students to this information or and medical schools could take a more active role in this provide direct support through outreach. process. Medical schools should also more clearly em- phasise that non-clinical experience of working with Understanding medicine and medical careers people is relevant and useful. There were also barriers in For younger students, the main knowledge gap related the way NHS organisations offer and arrange work ex- to the nature of medicine and breadth of medical ca- perience, therefore universities may work with NHS or- reers, meaning that students may have a limited view of ganisations to facilitate and promote work experience what medicine involves and the range of career options options. available within the profession. Students appeared to recognise diagnostic and procedural activities in medi- Course content, university life and finance cine but did not identify other activities including re- Students were uncertain about the academic chal- search, training, service development, public health or lenges of Higher Education, the change in learning the spectrum of patient groups. This may contribute to style required and social issues such as accommoda- perceptions that medicine is a narrow career. tion and adjusting to university life. This was particu- These early perceptions of what a career in medi- larly pertinent where students had few relatives and cine involves could also have impact on the future contacts to approach. Medical schools could provide workforce. For example, ‘talking to people with mental outreach sessions in association with existing univer- health problems’ wasidentifiedasamedicalrole by sity undergraduate advice services. This information less than half of the groups, yet this skill is a major may be delivered by early-stage medical students, part of many specialties, including GP, emergency which were a preferred source of information about medicine and psychiatry – all of which have problems the courseoversenioruniversitystaff. with recruitment and retention [21]. A lack of aware- Although students felt socioeconomic status influ- ness of the range of activities common in medicine, enced access to knowledgeable advice and support, combined with an over-emphasis on the ‘exciting’ participants did not express concerns about elitism in emergency elements of medicine in some media may medical school itself. This is in contrast to earlier deter applicants who are attracted to the more em- findings. A focus group of 14–16-year-old students pathetic aspects of medicine. found adverse stereotypes of medical students as Martin et al. BMC Medical Education (2018) 18:117 Page 11 of 13 elitist were off-putting [16], while an interview study online or face-to-face. For online resources, potential of mature medical students from working-class back- measures include search engine optimisation – ensuring grounds reported a predominant ‘identity conflict’ that appropriate web pages are returned to naïve stu- [24] due to perceived social elitism in medical dents’ searches (we found that one relevant blog was not schools. We found students focused more on struc- returned in the first pages of Google hits). A list of ‘fre- tural than personal factors. This could have been due quently asked questions’ prominently accessible from to methodology, which may have elicited a focus on medical schools’ course information and admissions web external deterrents rather than personal feelings. pages could address students’ practical concerns. Equally, the emphasis on perceived inequality of op- First-hand accounts have the potential to address un- portunity, rather than intergroup difference, may certainties about course content and careers. These mean that cultural barriers are not as rigid as earlier could take the form of written or video blogs from exist- authors have suggested. ing students and junior doctors, or talks and question Finally, the cost of medical training is a concern for and answer sessions in outreach and open day events. students and signposting to information about student The involvement of those from similar backgrounds was finance and NHS bursaries will be essential. Medical identified as particularly helpful by some participants – schools should note that NHS student bursaries are providing not just knowledge, but also role-modelling of changing [25] and anticipate how these changes may people who may not fit a socioeconomic stereotype. affect Widening Participation students. Finally, while open days and visits are helpful, these were also seen as time-consuming in a busy school term Social capital as a barrier with exam pressures ahead. As McLachlan noted [14], The knowledge gaps identified may be salient to all pro- outreach events may be more effective. Visits to schools spective applicants, regardless of their socioeconomic may reach those who may not volunteer for open days, background. However, they are likely to be more acute or be identified by teachers as being interested. If they for those without knowledgeable support at home or encourage interaction with peers, they may have value in school. supporting those who feel isolated. Students who may While we did not set out to consider barriers in theor- particularly benefit from these initiatives include youn- etical terms, our findings indicate the importance of ger students, those not yet considering medicine and knowledge from formal and informal social networks. those who are undecided. These may be seen as a form of social capital. Social cap- ital is a sociological concept which describes aspects of Limitations an individual’s social context, including information, The study has some limitations which we acknowledge which can be translated into human capital [26]. Effect- here. ively, it is a mechanism by which social power relations The study took place within a single medical school; are replicated. It has been widely considered in the con- therefore, findings may not be transferable to other loca- text of education [27], and found to be an influence on tions. However, the locality is geographically and socio- access to higher education among particular groups [28]. economically diverse and we have captured a range of views from many Widening Participation students. Modes of support The sample of participants was outside the control Deficits of social capital cannot necessarily be simply of the researchers. While there was very high partici- remediated, but recognising it is not just knowledge, but pation among those attending MaD days, the risk of support which may be lacking may help to shape selection bias nonetheless exists at two levels: stu- strategies. dents are selected by their schools to attend MaD It is not necessarily enough that information is avail- days, and school participation is itself subject to able; it must be accessible to and navigable by the target self-selection. The issues uncovered may therefore not population. This too can vary with the home and school be representative of students in other schools. Despite context of the student. Widening Participation students this, identifying problems faced by even a small pro- may need additional guidance on how to find and navi- portion of the theoretical population is still potentially gate resources if they do not have people around them useful. who can point them in the right direction. Younger Methodologically, the need to fit into the existing school students in particular may need school teachers format of the MaD days necessitated a pragmatic ap- or careers advisors to introduce the possibility of med- proach to data collection with a difficult-to-access ical career if it is not part of their home milieu. group. This involved compromises between the time We recommend that medical schools review how they available and the depth of data accessible. Rapid in- collate and signpost information, whether provided terpretation of findings was needed to feed into Martin et al. BMC Medical Education (2018) 18:117 Page 12 of 13 subsequent sessions. However, the consistency of Availability of data and materials The datasets used and/or analysed during the current study are available findings across different approaches gives them from the corresponding author on reasonable request. credibility. The research was conducted in large part by Authors’ contributions Conception of study: BB and GV. Development of workshop activities and current medical students working as student interns data collection: AM, BJB, GW, NW, AC, GV, BB. Data analysis: BB, with on the project (AM, BJB, GW and NW). While this interpretation by all other authors. Initial drafting of manuscript: BB and AM. contained a risk of bias in their having recent, and Critical revision of manuscript: BJB, GW, NW, AC, GV. Final approval of manuscript and acceptance of accountability for research: AM, BJB, GW, NW, successful, experience of applications and admissions AC, GV, BB. processes, their understanding was felt to be a strength in design and interpretation of the research. Authors’ information At the time of the study AM, BJB, GW and NW were medical students at All sessions were observed and data reviewed by a Newcastle University and AC an Academic Foundation Programme doctor non-clinician researcher (BB) which provided balance. on academic placement in the School of Medical Education. BB is Lecturer in No authors are currently involved in admissions Medical Education, and GV Senior Clinical Lecturer and Honorary Consultant, both in the School of Medical Education, Newcastle University. processes. Ethics approval and consent to participate This study was approved by the Newcastle University Faculty of Medical Conclusions Sciences Research Ethics Committee (Reference: 00906/2015). Written Students who may wish to consider medicine as a career informed consent to participate in the study was obtained from participants’ parents or legal guardians, or in the case of participants over 16 but under need reliable, structured information. A lack of awareness 18, written formal informed assent was accepted as meeting ethical of key areas of medical education and careers is wide- requirements. spread and those without access to relevant expertise at Consent for publication home or school have less opportunity to address this. As part of the process of informed consent, participants/parents or guardians Medical schools have a key role in widening participation were asked to provide consent for anonymised data to be included in and should facilitate access to reliable information publications. All who consented to participate gave this consent. through different modalities, including structured online Competing interests resources and through outreach delivered by a range of The authors declare that they have no competing interests. staff and students. The wide range of careers available within medicine Publisher’sNote should be emphasised in order to engage those who may Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. not have as much interest in more high-profile areas of medicine. Medical schools may also facilitate peer support Author details 1 2 for students who feel isolated in applying to medicine and Newcastle University, Newcastle-upon-Tyne, UK. School of Medical Education, Newcastle University, Ridley Building 1, Newcastle-upon-Tyne NE1 work with local NHS organisations to facilitate fair access 7RU, UK. to work experience opportunities. Future research should focus on evidence-based initiatives to inform and encour- Received: 15 June 2017 Accepted: 2 May 2018 age applicants to ensure that students from less advan- taged backgrounds are not excluded from medicine. References 1. Steven K, Dowell J, Jackson C, Guthrie B. Fair access to medicine? Abbreviations Retrospective analysis of UK medical schools application data 2009-2012 GP: General practice; MaD days: Medical and dentistry days; NHS: National using three measures of socioeconomic status. BMC Medical Education. Health Service; SES: Socio-economic status; UCAS: Universities and Colleges 2016;16(1):11. Admissions Service; UKCAT: United Kingdom Clinical Aptitude Test; 2. Milburn A: Fair Access to Professional Careers. London: Cabinet Office; 2012. WP: Widening participation https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/61090/IR_FairAccess_acc2.pdf. Accessed 23 May 2018. 3. Department for Business Innovation and Skills: Fulfilling our potential: teaching Acknowledgements excellence, social mobility and student choice: Her Majesty's Stationery Office; The authors would like to thank everyone who supported the research, 2015. https://assets.publishing.service.gov.uk/government/uploads/system/ particularly Dr. Paul Paes, Sub-Dean for MBBS Recruitment and Admissions; uploads/attachment_data/file/523420/bis-16-261-he-green-paper-fulfilling-our- Dr. Jo Matthan, Lecturer in the School of Medical Education; and Felicity Ste- potential-summary-of-responses.pdf. Accessed 23 May 2018. phenson, Student Recruitment Officer in the Faculty of Medical Sciences. The 4. Medical Schools Council. Selecting for Excellence Final Report. London; involvement of schools, teachers and the students who participated is also Medical Schools Council: 2014. https://www.medschools.ac.uk/media/1203/ recognised with gratitude. selecting-for-excellence-final-report.pdf. Accessed 23 May 2018. 5. Global Consensus for Social Accountability of Medical Schools: Consensus Funding document. 2010. http://healthsocialaccountability.org/. Accessed 23 May 2018. The project was supported by an Innovation Fund award from the 6. Castillo-Page L: Diversity in medical education: Facts & Figures 2012. Newcastle University Learning, Teaching and Student Experience Committee. Washington DC Association of American Medical Colleges; 2012. https:// This funding supported the employment of authors AM, BJB, GW and NW as members.aamc.org/eweb/upload/Diversity%20in%20Medical%20Education_ student interns in 2015–16. The funding committee had no role in the Facts%20and%20Figures%202012.pdf. Accessed 23 May 2018. design or execution of the study, analysis or interpretation of the results, 7. Behrendt L, Larkin S, Griew R, Kelly P: Review of higher education access reporting or development of this manuscript. and outcomes for aboriginal and Torres Strait islander people: final report. Martin et al. BMC Medical Education (2018) 18:117 Page 13 of 13 Canberra, ACT, Australia: Australian Government Department of Education and Training; 2012. https://docs.education.gov.au/system/files/doc/other/ heaccessandoutcomesforaboriginalandtorresstraitislanderfinalreport.pdf. Accessed 23 May 2018. 8. Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of first-year students in Canadian medical schools. CMAJ. 2002;166(8):1029–35. 9. Prideaux D, Roberts C, Eva K, Centeno A, McCrorie P, McManus C, Patterson F, Powis D, Tekian A, Wilkinson D. Assessment for selection for the health care professions and specialty training: consensus statement and recommendations from the Ottawa 2010 conference. Med Teach. 2011; 33(3):215–23. 10. Arulampalam W, Naylor R, Smith J. Doctor who? Who gets admission offers in UK medical schools. Coventry: University of Warwick; 2005. https:// warwick.ac.uk/fac/cross_fac/healthatwarwick/newsandevents/past_events/ seminar_series_20056/wiji.pdf. Accessed 23 May 2018. 11. Dowell J, Norbury M, Steven K, Guthrie B. Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work. BMC Med Educ. 2015;15(1):165. 12. Cooter R, Erdmann JB, Gonnella JS, Callahan CA, Hojat M, Xu G. Economic diversity in medical education. Eval Health Prof. 2004;27(3):252–64. 13. Houston M, Osborne M, Rimmer R. Private schooling and admission to medicine: a case study using matched samples and causal mediation analysis. BMC Med Educ. 2015;15:136. 14. McLachlan JC. Outreach is better than selection for increasing diversity. Med Educ. 2005;39:872–5. 15. Sacker A, Schoon I, Bartley M. Social inequality in educational achievement and psychosocial adjustment throughout childhood: magnitude and mechanisms. Soc Sci Med. 2002;55:863–80. 16. Greenhalgh T, Seyan K, Boynton P. “Not a university type”: focus group study of social class, ethnic and sex differences in school pupils’ perception about medical school. Br Med J. 2004;328:1541. 17. Kamali AW, Nicholson S, Wood DF. A model for widening access into medicine and dentistry: the SAMDA-BL project. Med Educ. 2005;39:918–25. 18. Cleland J. Taking context seriously: explaining widening access policy enactments in UK medical schools. Med Educ. 2015;49:25–35. 19. Powis D, Hamilton J, McManus I. Widening access by changing the criteria for selecting medical students. Teach Teach Educ. 2007;23:1235–45. 20. Kemmis S, Mctaggart R. The action research planner. 3rd ed. Victoria: Deakin University; 1988. 21. British Medical Association. Workload, recruitment, retention and morale: a BMA member briefing for the 2 May 2016 Special Representative Meeting. p. 2016. https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/ influence/key%20negotiations/doctors%20pay/bma-evidence-to-ddrb- sept2016-annex-srm-2016-workforce-briefing.pdf. Accessed 23 May 2018. 22. Jeremy Hunt unveils plan to fine doctors who move abroad after training. http:// www.independent.co.uk/news/uk/politics/jeremy-hunt-plans-to-fine-doctors- who-move-abroad-after-training-a7343531.html. Accessed 23 May 2018. 23. British Medical Association: Expansion of Undergraduate Medical Education [Response to DH consultation]. Compiled by Jethwa R; 2017. https://www. bma.org.uk/-/media/files/pdfs/collective%20voice/influence/ uk%20governments/bma-full-submission-expansion-of-undergraduate- medical-education-25-may-2017.pdf. Accessed 23 May 2018. 24. Mathers J, Parry J. Why are there so few working-class applicants to medical schools? 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BMC Medical EducationSpringer Journals

Published: May 30, 2018

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