editorial Equality, diversity and fairness in medical education: international perspectives Maria Tsouroufli1 & Irene Malcolm2 Among the key challenges addressed by this special ‘state of the science’ issue of Medical Education is that of increasing the conceptual sophistication of our accounts of equality, diversity and fairness in medical education. To this end, the journal seeks to introduce new perspectives to the field by bridging the gap between social sciences and medical education research. Our aim is to bring to the fore cutting-edge research on equality, diversity and fairness in medical education, informed by current theoretical debates and conceptual innovations in the social sciences. In particular, we wish to make a contribution to critical thinking about the conceptualisation, investigation and theorisation of relevant topics and highlight the implications for the education and practice of health care professionals. We invited submissions that would raise critical consciousness1 of equality, diversity and fairness in international contexts of medical education and suggest new research agendas in the field. We welcomed theoretically informed papers, empirical papers (quantitative, qualitative or mixed-methods 1 Institute for Policy Studies in Education, Faculty of Social Sciences and Humanities, London Metropolitan University, London, UK 2 Centre for Academic Leadership and Development, Herriot-Watt University, Edinburgh, Scotland, UK
doi: 10.1111/medu.12601
4
research papers) and critical perspectives on any aspect of medical education (undergraduate, postgraduate and continuing professional development in medicine) from any country. We particularly welcomed submissions that move beyond existing evidence outlining the underrepresentation and exclusion of particular groups. We proposed submissions on many themes including but not limited to: the intersection of diversities; the problematisation of essentialist concepts of gender in medical education; critiques of existing research in equality, diversity and fairness in medical education; marginalisation, belonging and otherness in medical education and the implications for retention and success; comparative perspectives on inequalities and discrimination in medical education, and equality and diversities in medical curricula; innovative approaches to inclusive medical pedagogies, and diversities, progression and fairness in medical education and training. However, the bulk of the papers and those that were strongest focused mainly on critiques of and gaps in existing equality, diversity and fairness issues in relation to the three areas of professional performance, policy and recruitment in undergraduate medical education. As a result, we organised the special issue into these three areas and invited distinguished scholars from across the world to comment on some of the papers contained
within each theme in an attempt to promote academic dialogue and debate in the field. The first section deals with the important question of policy in medical education, and includes qualitative contributions from the UK,2 Canada3 and Taiwan.4 Contributions in this section problematise widening participation policy and call for more critical approaches to researching access, participation and outcomes in medical education. The first paper, entitled ‘Taking context seriously: explaining widening access policy enactments in UK medical schools’,2 reports on a qualitative study that aimed to elucidate differences in how widening participation policy is played out in local contexts. The second, ‘Seeking inclusion in an exclusive process: discourses of medical student selection’,3 uses discourse analysis to critique inherent assumptions embedded in widening participation policy discourses and practices and the implications for equality and fairness in medical education. The last, ‘Equal, global, local: discourses in Taiwan’s international medical graduate debate’,4 is concerned with challenges resulting from the internationalisation of medical education and in particular how discourses of equality of opportunity and outcome are mobilised and reframed by different stakeholders in attempts to gain legitimacy in a changing medical education policy context.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 4–6
editorial The central section of this issue deals with the ethically charged question of undergraduate recruitment to medical schools. Contributions in this section are embedded in different epistemological and methodological traditions and focus on different strands of diversity (gender, ethnicity and intersecting diversities). They problematise recruitment of medical students and highlight the need for further research in terms of gender, ethnicity and socio-economic background. The first paper includes a quantitative, multiplecountry contribution entitled ‘Impact of selection strategies on representation of underserved populations and intention to practise: international findings’.5 This paper discusses the effects of different selection strategies of medical schools aspiring to social accountability on the presence of students from underserved communities in their medical education programmes and student practice intentions. The second paper, entitled ‘Disadvantage and the “capacity to aspire” to medical school’,6 is a qualitative contribution from Australia. The authors use Appadurai’s anthropological concept of aspiration to understand the impacts of the intersecting inequalities of low socioeconomic and educational background in the representation of students in Australian medical schools. The third paper, entitled ‘Ensuring a fair and equitable selection of students to serve society’s health care needs’,7 reports on the evaluation in American medical schools of a programme aimed at the expanding of access to medical education to individuals from under-represented ethnic, racial and rural groups. The last, ‘Textual analysis of internal medicine residency personal statements: themes and gender differences’,8 analyses the personal statements of applicants
to US medical residency programmes. It provides novel insights into gendered constructions and understandings of doctoring and potential implications for the recruitment of medical students and the design of medical curricula. The final section deals with professional performance and includes quantitative contributions from scholars from Australia,9 England10 and the Netherlands.11 These contributions focus on the factors that mark doctors’ professional performance and how they intersect with social justice in increasingly complex and diverse societies. These papers highlight significant gaps in clinicians’ knowledge practices related to a range of structural issues such as recruitment and social capital. All three papers, although they differ in their theoretical positioning and focus, draw attention to entrenched inequalities within medical schools, and highlight potential implications for the conceptualisation and investigation of this area in medical education. The first paper, entitled ‘The interaction of socio-economic status and gender in widening participation in medicine’,9 draws on socio-cognitive theory and stereotype bias to explain why applicants from low socio-economic backgrounds might be disadvantaged in terms of selection and performance in an Australian medical school, particularly if they are female. The second paper, ‘Bridging the gap: the roles of social capital and ethnicity in medical student achievement’,10 presents a social network analysis aimed at examining homophily to investigate the impact of relationships on medical student achievement by ethnicity. The last paper, ‘Ethnic and social disparities in performance on medical school selection criteria’,11 reports on an analysis of academic and non-academic
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 4–6
selection criteria and the effects of differential performance between traditional and non-traditional medical school applicants. It has been a privilege to edit a special issue of a journal as prestigious as Medical Education and we would like to take this opportunity to thank all colleagues who submitted papers. Our thanks are also due to the team of international reviewers for their very valuable critical contributions. As educators, we have learned a great deal in this process. Although we were struck by the broad epistemological and methodological diversity of the papers we received, we would have liked to receive more from non-Anglophone regions and more qualitative articles. That said, we would note that a significant achievement of this issue is its foregrounding of the complexity of the social contexts in which clinical practice is located. Here, clinicians, along with other professionals, may be looked to for curative solutions,12 particularly in the face of the social injustice that the contributors to this issue describe so acutely. REFERENCES 1 Kumagai AK, Lipson ML. Beyond cultural competence: critical consciousness, social justice and multicultural education. Acad Med 2009;84:782–7. 2 Cleland JA, Nicholson S, Kelly N, Moffat M. Taking context seriously: explaining widening access policy enactments in UK medical schools. Med Educ 2015;49:25–35. 3 Razack S, Hodges B, Steinert Y, Maguire M. Seeking inclusion in an exclusive process: discourses of medical school student selection. Med Educ 2015;49:36–47. 4 Ho M-J, Shaw K, Liu T-H, Norris J, Chiu Y-T. Equal, global, local:
5
editorial discourses in Taiwan’s international medical graduate debate. Med Educ 2015;49:48–59. 5 Larkins S, Michielsen K, Iputo J et al. Impact of selection strategies on representation of underserved populations and intention to practise: international findings. Med Educ 2015;49:60–72. 6 Southgate E, Kelly BJ, Symonds IM. Disadvantage and the ‘capacity to aspire’ to medical school. Med Educ 2015;49:73–83. 7 Girotti J, Soo Park Y, Tekian A. Ensuring a fair and equitable
6
selection of students to serve society’s health care needs. Med Educ 2015;49:84–92. 8 Osman NY, Schonhardt-Bailey C, Walling JL, Katz JT, Alexander EK. Textual analysis of internal medicine residency personal statements: themes and gender differences. Med Educ 2015; 49:93–102. 9 Griffin B, Hu W. The interaction of socio-economic status and gender in widening participation in medicine. Med Educ 2015;49:103–13. 10 Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the
gap: the roles of social capital and ethnicity in medical student achievement. Med Educ 2015; 49:114–23. 11 Stegers-Jager KM, Steyerberg EW, Lucieer SM, Themmen APN. Ethnic and social disparities in performance on medical school selection criteria. Med Educ 2015;49:124–33. 12 Evetts J. Professionalism, value and ideology. Curr Sociol 2013;61:778–96.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 4–6
doi: 10.1111/medu.12601
4
research papers) and critical perspectives on any aspect of medical education (undergraduate, postgraduate and continuing professional development in medicine) from any country. We particularly welcomed submissions that move beyond existing evidence outlining the underrepresentation and exclusion of particular groups. We proposed submissions on many themes including but not limited to: the intersection of diversities; the problematisation of essentialist concepts of gender in medical education; critiques of existing research in equality, diversity and fairness in medical education; marginalisation, belonging and otherness in medical education and the implications for retention and success; comparative perspectives on inequalities and discrimination in medical education, and equality and diversities in medical curricula; innovative approaches to inclusive medical pedagogies, and diversities, progression and fairness in medical education and training. However, the bulk of the papers and those that were strongest focused mainly on critiques of and gaps in existing equality, diversity and fairness issues in relation to the three areas of professional performance, policy and recruitment in undergraduate medical education. As a result, we organised the special issue into these three areas and invited distinguished scholars from across the world to comment on some of the papers contained
within each theme in an attempt to promote academic dialogue and debate in the field. The first section deals with the important question of policy in medical education, and includes qualitative contributions from the UK,2 Canada3 and Taiwan.4 Contributions in this section problematise widening participation policy and call for more critical approaches to researching access, participation and outcomes in medical education. The first paper, entitled ‘Taking context seriously: explaining widening access policy enactments in UK medical schools’,2 reports on a qualitative study that aimed to elucidate differences in how widening participation policy is played out in local contexts. The second, ‘Seeking inclusion in an exclusive process: discourses of medical student selection’,3 uses discourse analysis to critique inherent assumptions embedded in widening participation policy discourses and practices and the implications for equality and fairness in medical education. The last, ‘Equal, global, local: discourses in Taiwan’s international medical graduate debate’,4 is concerned with challenges resulting from the internationalisation of medical education and in particular how discourses of equality of opportunity and outcome are mobilised and reframed by different stakeholders in attempts to gain legitimacy in a changing medical education policy context.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 4–6
editorial The central section of this issue deals with the ethically charged question of undergraduate recruitment to medical schools. Contributions in this section are embedded in different epistemological and methodological traditions and focus on different strands of diversity (gender, ethnicity and intersecting diversities). They problematise recruitment of medical students and highlight the need for further research in terms of gender, ethnicity and socio-economic background. The first paper includes a quantitative, multiplecountry contribution entitled ‘Impact of selection strategies on representation of underserved populations and intention to practise: international findings’.5 This paper discusses the effects of different selection strategies of medical schools aspiring to social accountability on the presence of students from underserved communities in their medical education programmes and student practice intentions. The second paper, entitled ‘Disadvantage and the “capacity to aspire” to medical school’,6 is a qualitative contribution from Australia. The authors use Appadurai’s anthropological concept of aspiration to understand the impacts of the intersecting inequalities of low socioeconomic and educational background in the representation of students in Australian medical schools. The third paper, entitled ‘Ensuring a fair and equitable selection of students to serve society’s health care needs’,7 reports on the evaluation in American medical schools of a programme aimed at the expanding of access to medical education to individuals from under-represented ethnic, racial and rural groups. The last, ‘Textual analysis of internal medicine residency personal statements: themes and gender differences’,8 analyses the personal statements of applicants
to US medical residency programmes. It provides novel insights into gendered constructions and understandings of doctoring and potential implications for the recruitment of medical students and the design of medical curricula. The final section deals with professional performance and includes quantitative contributions from scholars from Australia,9 England10 and the Netherlands.11 These contributions focus on the factors that mark doctors’ professional performance and how they intersect with social justice in increasingly complex and diverse societies. These papers highlight significant gaps in clinicians’ knowledge practices related to a range of structural issues such as recruitment and social capital. All three papers, although they differ in their theoretical positioning and focus, draw attention to entrenched inequalities within medical schools, and highlight potential implications for the conceptualisation and investigation of this area in medical education. The first paper, entitled ‘The interaction of socio-economic status and gender in widening participation in medicine’,9 draws on socio-cognitive theory and stereotype bias to explain why applicants from low socio-economic backgrounds might be disadvantaged in terms of selection and performance in an Australian medical school, particularly if they are female. The second paper, ‘Bridging the gap: the roles of social capital and ethnicity in medical student achievement’,10 presents a social network analysis aimed at examining homophily to investigate the impact of relationships on medical student achievement by ethnicity. The last paper, ‘Ethnic and social disparities in performance on medical school selection criteria’,11 reports on an analysis of academic and non-academic
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 4–6
selection criteria and the effects of differential performance between traditional and non-traditional medical school applicants. It has been a privilege to edit a special issue of a journal as prestigious as Medical Education and we would like to take this opportunity to thank all colleagues who submitted papers. Our thanks are also due to the team of international reviewers for their very valuable critical contributions. As educators, we have learned a great deal in this process. Although we were struck by the broad epistemological and methodological diversity of the papers we received, we would have liked to receive more from non-Anglophone regions and more qualitative articles. That said, we would note that a significant achievement of this issue is its foregrounding of the complexity of the social contexts in which clinical practice is located. Here, clinicians, along with other professionals, may be looked to for curative solutions,12 particularly in the face of the social injustice that the contributors to this issue describe so acutely. REFERENCES 1 Kumagai AK, Lipson ML. Beyond cultural competence: critical consciousness, social justice and multicultural education. Acad Med 2009;84:782–7. 2 Cleland JA, Nicholson S, Kelly N, Moffat M. Taking context seriously: explaining widening access policy enactments in UK medical schools. Med Educ 2015;49:25–35. 3 Razack S, Hodges B, Steinert Y, Maguire M. Seeking inclusion in an exclusive process: discourses of medical school student selection. Med Educ 2015;49:36–47. 4 Ho M-J, Shaw K, Liu T-H, Norris J, Chiu Y-T. Equal, global, local:
5
editorial discourses in Taiwan’s international medical graduate debate. Med Educ 2015;49:48–59. 5 Larkins S, Michielsen K, Iputo J et al. Impact of selection strategies on representation of underserved populations and intention to practise: international findings. Med Educ 2015;49:60–72. 6 Southgate E, Kelly BJ, Symonds IM. Disadvantage and the ‘capacity to aspire’ to medical school. Med Educ 2015;49:73–83. 7 Girotti J, Soo Park Y, Tekian A. Ensuring a fair and equitable
6
selection of students to serve society’s health care needs. Med Educ 2015;49:84–92. 8 Osman NY, Schonhardt-Bailey C, Walling JL, Katz JT, Alexander EK. Textual analysis of internal medicine residency personal statements: themes and gender differences. Med Educ 2015; 49:93–102. 9 Griffin B, Hu W. The interaction of socio-economic status and gender in widening participation in medicine. Med Educ 2015;49:103–13. 10 Vaughan S, Sanders T, Crossley N, O’Neill P, Wass V. Bridging the
gap: the roles of social capital and ethnicity in medical student achievement. Med Educ 2015; 49:114–23. 11 Stegers-Jager KM, Steyerberg EW, Lucieer SM, Themmen APN. Ethnic and social disparities in performance on medical school selection criteria. Med Educ 2015;49:124–33. 12 Evetts J. Professionalism, value and ideology. Curr Sociol 2013;61:778–96.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 4–6
