Adv in Health Sci Educ DOI 10.1007/s10459-014-9550-4

Medical school personal statements: a measure of motivation or proxy for cultural privilege? Sarah Wright

Received: 15 November 2013 / Accepted: 23 August 2014  Springer Science+Business Media Dordrecht 2014

Abstract Students from state schools are underrepresented in UK medical schools. Discussions often focus on deficient academic and motivational traits of state school students, rather than considering the effects of student support during the admissions process. This qualitative study explored student experiences of support from schools and families during the medical school admissions process with particular focus on the personal statement. Interviews were conducted with thirteen medical students at a British medical school who had each attended a different secondary school (classified as private or state funded). A thematic analysis was performed. Bourdieu’s concepts of capital and field were used as a theoretical lens through which to view the results. Interviews revealed substantial differences in support provided by private and state funded schools. Private schools had much more experience in the field of medical school admissions and had a vested interest in providing students with support. State schools were lacking by comparison, offering limited support that was often reactive rather than proactive. Students from private schools were also more likely to have social contacts who were knowledgeable about medical school admissions and who could help them gain access to work experience opportunities that would be recognised as legitimate by selectors. While medical schools endeavour to make fair admissions policies, there is an unintended link between a student’s access to capital and ability to demonstrate commitment and motivation on personal statements. This helps explain why academically capable but financially or socially challenged students are less likely to be recognised as having potential during the admissions process. Medical schools need to be challenged to review their admissions policies to ensure that the do not inadvertently favour cultural privilege rather than student potential.

S. Wright (&) Medical Education Department, Toronto East General Hospital, 825 Coxwell Avenue, Toronto, ON M4C 3E7, Canada e-mail: [email protected] Present Address: S. Wright Centre for Ambulatory Care Education, Toronto, ON, Canada

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Keywords

Admissions
Bourdieu
Inequality
Personal statements
Non-Academic

Introduction There has been a notable shift from assessing academic traits to non- academic traits when making medical student selection decisions. In the UK, grade inflation has made it increasingly difficult for medical schools to distinguish between academically qualified applicants. There are also concerns that privately educated students are more likely to receive top A level (high school) grades, sparking concern that reliance on academic criteria at these elevated levels favours privately educated students (Braconier 2012; Lumsden et al. 2005; Powis et al. 2007; The Sutton Trust 2008b). Finally, there is wide acknowledgement that academic ability alone does not guarantee a student will become a ‘good’ doctor and desirable traits of medical students should be identified during the admissions process such as good communication skills, honesty, integrity, and empathy (Council of Heads of Medical Schools 2006; GMC 2009; Powis 2003). Arguably, attempting to identify such traits is more challenging than determining whether a candidate has met an academic threshold. Assessing personal statements has become a popular method of selecting and rejecting students for medical student interviews (Parry et al. 2006; Turner and Nicholson 2011). The majority of UK medical schools reportedly use the personal statement; a 400 word essay, submitted by all UK university applicants to a central body known as Universities and Colleges Admissions System (UCAS) (Parry et al. 2006). The theory behind using the personal statement is that it is the applicant’s chance to demonstrate their suitability for the medical course through describing their experiences and achievements. The personal statement also serves a practical purpose in that it is not feasible to interview every applicant given the high demand for medical school places; and the personal statement provides an inexpensive way to screen applicants before deciding which applicants to interview. While medical schools are not uniform in their assessment of personal statements, many report looking for evidence of: motivation and commitment to a medical career, team work, leadership, responsibility; extra-curricular interests and health or social care work experience (Parry et al. 2006). Despite the widespread use of personal statements, their reliability and validity have been questioned. For example, it is difficult to determine whether applicants have written the personal statements themselves. In 2007, it was reported that there were about 800 cases of UK medical school personal statements that contained similar material; 234 of which referred to becoming interested in medicine after accidentally setting fire to their pyjamas as a child (Frean 2007). While software is now being routinely used by UCAS to identify cases of borrowed material and plagiarism in personal statements (Universities and College Admissions Service 2011), it cannot identify cases of a third party writing an applicant’s personal statement or whether the material presented is accurate and truthful. As a recent study suggests, it is possible that applicants fabricate and exaggerate details in their personal statements (Kumwenda et al. 2013). A 2010 study challenged the validity of personal statements through quantitative analysis, finding that privately educated students scored significantly higher on personal statements than state educated students; yet neither

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personal statements nor secondary school type were significant predictors of medical school performance (Wright and Bradley 2010). Nevertheless, the content contained in personal statements can be a powerful influence over selector decisions regarding an applicant’s suitability for a medical course. A recent study conducted at a London medical school provided some insight as to what selectors are looking for when deciding whether to accept or reject applicants (Turner and Nicholson 2011). Work experience, extracurricular activities, attending conferences related to medical school and reading medical literature served as a proxy for commitment and motivation to study medicine (Turner and Nicholson 2011). Selectors reported favouring applicants whose personal statements contained details of medical work experience, and rejecting those with no medical work experience, or those who did not have ‘enough’ work experience (Turner and Nicholson 2011). However, selectors were unable to arrive at a consensus for what constituted ‘enough,’ suggesting the subjective nature of this selection method (Turner and Nicholson 2011). Whilst there was some acknowledgement that students from different backgrounds do not have equal access to work experience opportunities or extracurricular activities, selectors had differing opinions on how to handle such situations (Turner and Nicholson 2011). The onus is on prospective students to demonstrate their possession of desirable attributes in ways that are recognised by medical school selectors throughout the admissions process. However, little is known about how prospective medical students find out what information and activities should be included, how they gain access to such activities and what type of support is provided when writing the personal statement. Although concerns have been raised by the British Medical Association that opportunities to participate in such events may not be equally accessible to all eligible applicants, this area has received little attention in medical education research (British Medical Association 2004; Milburn 2012). The current study addresses an important issue highlighted by The Fair Access to the Professions report, which cited a ‘lack of progress’ in promoting fair access to the medical profession in the UK (Milburn 2012). This retrospective qualitative study explored the types of support available to students during the admissions process; with particular focus on personal statements, given the findings of Wright and Bradley (2010) and their strong influence on a student’s chances for success during the admissions process (Turner and Nicholson 2011). Pierre Bourdieu’s concepts of field, capital and habitus have been used as theoretical lens through which to view the results. A brief outline of these concepts are provided below, along with justification for their application to the medical school admissions setting.

Theoretical framework A central concept of Bourdieu’s work is capital, which he classifies into different forms: economic, social, cultural and symbolic (Bourdieu 1986). Economic capital is the most recognisable form of capital, relating to the wealth possessed by individuals. Social capital refers to personal connections and networks. Cultural capital can be defined as ‘‘a form of value associated with culturally authorised tastes, consumption patterns, attributes, skills and awards’’ (Webb et al. 2002; p. x). Symbolic capital is a less obvious form of capital relating to reputation and prestige; its existence depends on the belief by others that an individual or institution possesses such capital (Baert and Carreira da Silva 2010). For

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example, the British Monarchy relies on the belief of the people that they are worthy of their prestigious position. The forms of capital are interrelated and often reproductive; a career in medicine is likely to provide economic capital through remuneration, cultural capital by the license to practice medicine, symbolic capital by holding a prestigious profession and social capital through associating with others in similar positions. According to Bourdieu, agents are in competition for these forms of capital, within arenas he designates as ‘fields’ (Webb et al. 2002). While some agents are experienced in a given field, those who are new to the field may struggle to recognise and/or obtain valued forms of capital. Bourdieu argues that capital is the reason why opportunities are not equally possible or impossible for everyone (Bourdieu 1986). The ability to access such forms of capital is dependent upon what Bourdieu refers to as ‘habitus;’ loosely described as an accumulation of values and dispositions influenced by past experiences, which shape future behaviour (Bourdieu 1973). Habitus is a way of understanding the complex phenomenon of individual behaviour in the context of societal structure. While habitus is a combination of the influences of both structure and agency, Bourdieu argues that (dis)advantages are more often reproduced than they are transformed, due to the strong influence of societal structures on behaviour (Bourdieu 1973). While this view has led to criticisms that his theories are ‘too deterministic’ (Sullivan 2001), the concept of habitus allows behaviour to be interpreted as a product of both structures and individual agency, setting him apart from pure structuralist theorists. Educational settings are a key context upon which Bourdieu’s theories are based. Researchers have successfully applied his theories in the medical education setting; for example, Brosnan analysed the way the field of medical education is shaped by the competition for capital amongst medical schools (Brosnan 2010). The current study retrospectively analyses the struggle for capital among individual applicants during the admissions process; highlighting positions of relative dominance and subservience based upon the level of (legitimate) capital available through schools and families. This paper proposes that the different positions occupied by medical school applicants must be taken into account when discussing the reasons for the underrepresentation of state educated students in UK medical schools and when admissions policies are being decided upon. While the study was conducted in the UK context, the application of Bourdieu’s theories to the field of medical school admissions is likely appropriate in other contexts.

Methods The findings reported here form the latter half of a mixed methods study underpinned by the author’s pragmatic worldview. While some researchers argue that using quantitative and qualitative methods within a single study is problematic, pragmatism argues that the research question should be prioritised over philosophical commitments (Cresswell and Plano Clark 2011). Arguably, the pragmatic worldview is consistent with Bourdieu’s concept of habitus which is predicated on the rejection of a purely objective or subjective epistemological stance. Instead, the concept of habitus seeks to better understand the interplay between societal influence and individual agency, necessitating investigations combining both objective and subjective points of view (Bourdieu 1973, 1986). The overall purpose of the mixed methods study was to evaluate the ability of admissions tools to predict medical school performance. A sequential explanatory design was used, beginning with a predictive validity study employing a regression analysis,

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reported elsewhere (Wright and Bradley 2010). The regression analysis found that state educated students scored significantly lower on the personal statement than did their privately educated counterparts, yet personal statements did not predict medical school examination performance (Wright and Bradley 2010). Interviews were used to complement the quantitative analysis by exploring reasons for the difference in personal statement scores by inquiring about the support available to students when preparing their medical school applications. Although the current paper focuses on student support during the admissions process, the interviews served an alternate purpose of investigating the reasons why medical student performance cannot be predicted with great accuracy. While both interview topics were used to complement the results of the regression analysis, only one sampling strategy could be used to select participants. Thus, a purposive sample of students whose medical school examination scores were higher than, lower than, or as predicted by admissions scores (which included personal statement, interview and UKCAT) were invited to participate, which targeted students who did not fit the ‘prediction mould.’ Although this sampling strategy was not directly intended for the current analysis, the sample contained a mix of students from private and state-funded schools, which enabled an exploration the types of support these students received from their schools and families. A total of twenty-nine students were invited to participate, which resulted in thirteen semi-structured interviews. Six participants had attended (fee-paying) private schools and seven had attended state-funded schools. No two participants attended the same secondary school. There was a fairly even spread of gender, with seven females (four state-funded, three private) and six male participants (three state-funded, three private). All thirteen participants were from the 2007–2008 entering cohort of medical students at Newcastle University, which is a Russell Group (research intensive) university located in the northeast of England. Interviews were conducted at the university between June and November 2010 (when participants were either in their third or fourth year of medical school), lasting between 45 and 90 min each. The Faculty of Medical Sciences Ethics Committee granted ethical approval for the study, and participants were assured that their responses would remain anonymous. The author transcribed the recordings verbatim. A thematic analysis was conducted using the steps outlined by Framework Analysis: familiarisation, identifying a thematic framework, indexing, charting, mapping and interpretation, and writing (Ritchie and Spencer 1994). Data were organised and stored in NVIVO software, where an initial coding structure was established and refined by the author (SW). Following the initial coding process, a thematic framework matrix was created which allowed themes to be compared both within and across cases (Ritchie and Spencer 1994). The work of Pierre Bourdieu was used as a theoretical lens through which to view the results.

Results Experience in the ‘field’ of medical school admissions Interviews with privately educated students reflected schools that were routinely competing in the field of university and medical school admissions, while many state school participants spoke of experiences reflecting schools that had little or no experience in this field. Private schools provided a culture in which going to university was a deeply embedded certainty for their students:

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I was at a private school and…that was very much the idea that we were brought up with. It never really crossed my mind not to go to university. (Interview 10, private school) It was also suggested that parental decisions to fund private education were made based upon the perception that private schools have an increased ability to facilitate university entry. In other words, the prospect of university entry made private education seem worth the financial sacrifice for those who could afford it; reportedly an average of £10,100 a year in the UK for day pupils (Benn 2011). In order to legitimise their own existence, private schools need to distinguish themselves from state schools by offering a competitive advantage to their students in addition to providing an education. In order to survive, private schools must attract students to provide economic capital through tuition fees. A major way to do so is through reputation, a form of symbolic capital, which relies heavily upon higher education entry statistics. The desire for private schools to produce university entrants was evident through interview discussions, which suggested that non-university career options were actively discouraged, to the point that students felt stigmatised for expressing an interest in such options. It was also suggested that private schools were openly concerned about the impact on their league table standings if students entered careers which did not involve university study. Arguably, private schools are in the business of competing in the field of university admissions. In addition to discouraging non-university options, private schools focussed considerable effort on developing strategies to ensure admissions success for their students. Interviews revealed the developed expertise of private schools in meeting medical selector expectations: Their expertise was sort of, not playing the system, but understanding the rules about how to get into university and how to maximise your chances of doing what you want. (Interview 10, private school) For some reason our school tended to be quite good at churning out medical students… In our year, out of 105 of us, I think 17 got offers to do medicine. (Interview 3, private school) While the schools help students achieve their career goals, they are also serving their own purpose in their quest for the symbolic and cultural capital associated with being perceived as a ‘good school.’ This competition for capital has a reproductive effect; having a reputation for getting students into prestigious university courses will make the school desirable, attracting further economic capital through tuition fees, which helps to further facilitate university entry through tailored careers support for students. In contrast, state schools were considerably less experienced and in some cases, not engaged at all with the field of university and medical school admissions. State educated participants often viewed this as a deficit of their own schools, rather than as an ‘added bonus’ provided in private schools; perhaps indicating a perceived inferiority of state school positioning relative to private schools in the field of medical school admissions. Some participants attributed the lack of advice to a lack of demand from their fellow students: No offense to the school, [but] I don’t think they would get many people going on to do courses like medicine. (Interview 1, state school)

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There just wasn’t enough demand. I was the only person going to medical school… They’d only ever had 2 others before me. I just don’t think they were aware of the medical school system. (Interview 7, state school) This highlights the effects of the complex English secondary education system which has retained elements of academic and social selection in state-funded schools (Benn 2011; The Sutton Trust 2008a). These selective elements result in the most disadvantaged students being clustered within the same schools, affecting which courses are offered, academic outcomes and resultant university eligibility (Benn 2011; Coughlan 2012). Furthermore, this segregation can influence the culture of the school such that competitive courses like medicine may be perceived as outside the realm of possible career options. The lack of careers advice was also associated with a perceived lack of resources in state schools: We had a very broad range of people in terms of academic ability[…] they didn’t have the time and resources to put into all of us. (Interview 7, state school) Where I come from is quite poor… they just don’t have the resources at school to be able to learn as well as, you know, private schools. (Interview 4, state school) These quotations highlight well-documented consequences of socially segregated schools; the most disadvantaged schools often have lower teacher to student ratios and poorer quality teaching resources (Benn 2011; Braconier 2012). Aside from delivering secondary education, state and private schools in the UK seem to have two different foci. As demonstrated in above, some state schools were described as being focused on providing secondary education to a diverse population of students, with careers guidance and university applications often falling outside of this remit. Conversely, private schools were described as being primarily focused on securing university places for all students, with academic achievement forming a key component of this overall goal. These philosophical differences with regard to the school’s purpose, coupled with higher levels of economic capital in private schools contribute to the differences in admission support available to students in the different school types. Yet, students from all school types are expected to meet the same admissions requirements and are typically evaluated as equals by admissions selectors. The drive for capital Work experience was described as being a priority within private schools, with time specifically allocated to it during the school week and advice given on what experiences were appropriate: Thursday afternoon was called activities afternoon […] You got to choose loads of different things you wanted to do. […] They suggested that I go work in a hospice, so every Monday lunchtime I’d go in and help out there. (Interview 10, private school) Privately educated participants reported being encouraged to build up a portfolio of work experience opportunities long before applications would be made, some having started the process as early as age of thirteen. Schools were a major source of the social capital often required to secure such experience:

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They made sure that everyone knew that you had to have the work experience…if you couldn’t find your own placement they helped you find somewhere to go. (Interview 13, private school) They tailored subjects to whatever you wanted to study, and then they helped you get work experience to put into personal statements. (Interview 12, private school) Thus, private schools were able to draw upon their cultural capital (knowing what medical schools wanted to see) and social capital (connections with other organisations that could offer their students work experience) in order to obtain work experience opportunities for their pupils, with the goal of increasing their own symbolic capital (school reputation). In contrast, careers advice in state schools was often described as being reactive rather than proactive. Career and university discussions were described as taking place much later in state schools: After you got [predicted] grades, [that’s when] they’d have a chat about your options. (Interview 11, state school) The ability to provide careers support offers students in schools with the most capital an advantage over those with the least amount of capital. This advantage is further enhanced by the earlier application deadline of October for medicine, compared to the January deadline for most other courses (Universities and College Admissions Service 2011). Given that predicted grades are typically based on the grades from the penultimate year of A levels, and UK medical applications are due in October, this leaves only a few months in which a student can attempt to organise and write about relevant work experience. Clearly, this positions privately educated students at a considerable advantage over those in the state sector, since those with early career advice are more likely to satisfy selector requirements of having ‘enough’ relevant work experience (Turner and Nicholson 2011). Some state schools are currently struggling to provide careers advice at all, let alone providing tailored advice as early as age thirteen, due to lack of resources (Careers England 2012): Where I come from, we didn’t have any of that! I think we had work experience when I was in 4th year but I ended up doing something that I didn’t really want to do. (Interview 4, state school) Thus, options for work experience are influenced by the opportunities made available by the schools; not necessarily upon student motivation and commitment to medical study. Since private schools are more actively engaged than other schools in the competition for capital in the field of medical school admissions, they are also in a position to dictate what forms of capital should be valued by selectors. For example, work experience was not always a requirement for medical school, making those who had it a distinguished group. Nowadays, having some work experience has become an expectation of medical school selectors; however, starting medical work experience at the age of thirteen provides distinction for those familiar with the field of medical school admissions, as it remains an unlikely possibility for the majority. A ‘link on the inside’ Families were also a main source of social capital required to secure work placements; although students who benefitted from private education often made references to well-

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connected family members. This ‘double advantage’ has been reported by others (Pugsley 2004). In some cases, schools identified the need for work experience, and the student’s family then provided social connections to secure the opportunity: [The school] gave suggestions but I had to go out and find doctors and hospitals that would take me on. […] Well, with help from family who knew people. (Interview 3, private school) I did a bit of work experience with my dad’s doctor and in my old paediatrician’s practice. […] It was quite easy for me to get that, it was just literally a case of just calling them up. Sometimes it wasn’t even me who called them up it was my dad. (Interview 10, private school) Having a parent in the medical profession proved useful in accessing hospital work experience, which was perceived both as a selector expectation and as a significant hurdle to those without medical connections: [My dad] was the one who got me work experience… it’s a nightmare to try to apply to hospital to get to do work experience, just because of all of the confidentiality things. So had I not had a link on the inside, I don’t think I could have done it. (Interview 9, state school) Since personal statements are often used as a screening tool for interview, and work experience forms a key part of the screening, students who struggle to identify what is expected by selectors or lack the social capital to gain such experience are unlikely to be recognised during the admissions process as being motivated and committed to a career in medicine. Furthermore, not all work experience was considered ‘legitimate’ by selectors. While the current research was limited to those students who were successful in their medical school applications, one participant who entered with a first class honours degree in forensic science discussed the experience of rejection before eventually being accepted: I got a job as a mortar technician for 5 years. I was dealing with post-mortem examinations and also dealing with families as well. I applied a couple of years for medical school but got rejected because they kept saying you need more healthcare experience. (Interview 4, state school) Arguably, 5 years as a mortar technician would provide more opportunities to develop skills desired of a medical student than a week shadowing a doctor; however, it was reportedly not recognised as form of legitimate healthcare experience by some selectors. This notion of ‘legitimate’ experience was highlighted by another candidate, who reported that she would have struggled to identify appropriate opportunities without help from her family: If I didn’t have a doctor for a parent… I wouldn’t know where to begin. At that age, you don’t know the difference between a hospice and primary care and secondary care and all the different types of work experience. (Interview 9, state school) This quotation suggests schools and families experienced in the field of medical school admissions have insider knowledge about what ‘counts;’ presumably, this knowledge is inaccessible to those with little or no experience in the field. Selectors may assume a linear relationship between amount of work experience and motivation and commitment to study medicine. However, it was suggested that some

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schools facilitate work experience where little student motivation or commitment is required: They bring a whole load of disabled teenagers onto the private school grounds, they run the charity holiday, the students volunteer for a couple of days, they go home, they write it on their personal statement and the job’s a good one. (Interview 9, statefunded school) Another participant admitted to fabricating some of the information in his personal statement to satisfy the perceived requirement of having done ‘enough’ work experience: I didn’t lie, but I did stretch some things out, like work experience dates I think… the schools normally don’t mind because they want their university admissions figures up… they’ll actually sort of help you towards your lies. (Interview 2, private school) These statements present the possibility that competition for capital in the field of medical school admissions is so fierce among schools that, on occasion, dishonesty in personal statements is justified as a way to increase chances of being offered a medical school place. This represents a serious threat to the validity of personal statements as a true reflection of a candidate’s commitment and motivation to study medicine and has been highlighted as a concern by others (Kumwenda et al. 2013). Having a helpful school that facilitates work experience opportunities certainly does not preclude a student from being committed or motivated to study medicine. However, some concerns were raised that students who attended supportive schools did not have to interrogate their career choices in the same way as those who had less admissions support: Because medicine was so achievable from their school, they didn’t have to at any stage go, ‘Do I really, really want this? Am I really interested in people and medicine and science?’ (Interview 9, state school) Conversely, the inability to secure work experience cannot necessarily be interpreted as a lack of commitment and motivation to study medicine. However, it is clear that the emphasis on work experience in the admissions process leaves students attending schools that can neither identify nor facilitate relevant work experience opportunities at a significant disadvantage. However, this did not prevent all students at unsupportive schools from gaining relevant work experience: My granddad had a heart bypass so I wrote to his consultant and he let me go and do a week of cardio-thoracic with him. (Interview 7, state school) While this approach demonstrates resourcefulness and justifiably indicates commitment and motivation to study medicine, it is unreasonable to expect students in less experienced schools to rely on serendipitous opportunities to fulfil the requirement for work experience. Furthermore, it is unreasonable to believe that every consultant approached in this way would be as sympathetic to an unknown student’s request for work experience. This challenges the feasibility of the current selector expectations that all applicants should demonstrate they have undertaken ‘enough’ medical work experience; opportunities are clearly not equally accessible to all prospective medical students, the parameters of what constitutes ‘enough’ or ‘legitimate’ work experience are poorly defined, and there is little existing evidence to suggest work experience impacts medical school success.

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Writing the personal statement There were differences in the level of support given to students when writing personal statements. Students from private schools consistently described having abundant support in writing personal statements: We gave [it] in as many times as we wanted and they’d give them back to us and gave corrections, and what they thought we should have. (Interview 8, private school) There was one particular teacher who had a great interest in helping people get into medicine… he’d read through your personal statements, and give you suggestions on what was good, and what was bad… he put on these extra sort of seminars with medical students that he had got in, that were ex-pupils, who came to talk to us. (Interview 3, private school) This type of support allows students to communicate in a way which is likely to facilitate their recognition as legitimate candidates (Burke and McManus 2011). Students attending private schools benefitted from the staff having the cultural capital to know what information should be contained in personal statements and how it should be presented. This was in stark contrast to state educated pupils, some of whom described having never heard of the medical school experiences of others. While some state schools did offer support in personal statement writing, it was less comprehensive than that described in private schools: They did this thing where you… sent in your personal statement and they had a little read over it. (Interview 11, state school) [They told us] this is when it has to be in, [but] not really what you have to do… there wasn’t really much guidance about what to put down. (Interview 7, state school) Having social connections through teachers, families or peers, who are familiar with the type of activities and discourse that selectors recognise as demonstrative of student potential places these students at a significant advantage during the admissions process. In the current study, those from private schools were substantially more likely to benefit from such connections. This likely helps to explain the findings of a recent study in which state school students were three times more likely to have writing errors in their personal statements than were students from private schools (Jones 2012).

Discussion Summary The aim of this study was to explore the types of support students receive when preparing for medical school applications. Applying Bourdieu’s theories allows us to conceptualise medical school admissions as a field in which applicants occupy positions of relative dominance or subservience, based upon the level and quality of support (capital) available to them during the admissions process. Interview discussions with medical students suggested that those from private schools are more likely to benefit from social, cultural and

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economic capital. Like medical school applicants, private schools are also competing for capital; having students enter prestigious university courses like medicine helps to promote and preserve symbolic capital. Thus, private schools have a vested interest in being highly engaged with the field of university and medical school admissions. Interviews revealed that participants who had attended private schools were comparatively better informed of the types of activities selectors expect to see in personal statements, had the social connections in order to access such experiences and had the benefit of support when writing personal statements. State school students had considerably less support during the admissions process, making it more difficult for them to identify and gain access to the activities routinely recognised by selectors as demonstrative of potential. While the main purpose of this study was to gain understanding, rather than to make generalizations to wider populations, the results provide a possible explanation for the superior acceptance rates of privately educated students reported by others (Arulampalam et al. 2005; Milburn 2012). A challenge to validity The findings of this study also challenged selector assumptions that work experience indicates commitment and motivation for medical study, and that a lack of work experience indicates a lack of commitment and motivation for medical study. Interviews revealed that students from schools and families inexperienced with medical school admissions were more likely to struggle to identify and obtain access work experience opportunities that selectors would recognise as legitimate. The disparate level of support available to students from state and private schools help to explain the discrepant personal statement scores found by Wright and Bradley (2010). While having undertaken some work experience is likely an important step in making career decisions, there is very little evidence to suggest that work experience has any effect on medical student success; questioning role in the selection process. This is an area in need of further research. Limitations The sampling strategy used to identify participants is a limitation of the study. This analysis was part of a larger mixed methods study, and the purposive sample was selected based on a separate, yet related, line of inquiry related to medical student examination performance in relation to admissions performance. Nevertheless, the resultant sample provided a good mix of student experiences of support from different school types and the results have important implications for admissions teams. Further studies could include more targeted sampling. Another limitation of the study was that the interviews were conducted only with participants who had been successful in the admissions process. Within the sample, there was a wide range in the level of support available to applicants. It may be the case that even greater disparities are found if the sample of participants was expanded to include those who are not successful in the admissions process. Second, whilst the findings clearly demonstrated different focuses of state and private schools, a limitation of the study was that state schools were considered as a whole, despite acknowledgement that there is considerable variation within state-funded (and private) schools. Given the rapid changes to state-provided English secondary schooling under the Academies Act 2010, this is an area in need of further research (Benn 2011). Furthermore, Bourdieu’s work has been criticised for the assumed homogeneity among groups designated as being in possession of

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cultural capital (Sullivan 2001). The current study focused on similarities among students from the same school type, despite the author’s acknowledges that the possession of cultural capital is more complex. For example, a state school participant had a parent who was a doctor, and there are likely students attending private schools having little familial cultural capital. What can universities do? Engage in ‘‘critical reflexivity’’ Universities have been tasked with widening participation and creating fair access to the professions (Milburn 2012; Office of Fair Access 2011). Given the schooling inequalities highlighted by the current study, it may seem that universities have limited power to drive change. However, the findings also reflect deeply embedded institutional conceptions of student potential (Burke and McManus 2011); private schools employ strategies to identify activities and discourses which will be recognised by selectors as such, giving their students increased chances of being offered a medical school place. Such strategies remain successful because medical schools have yet to acknowledge the link between the ways in which potential is recognised by selectors and a student’s access to capital (Burke and McManus 2011). This is not to say medical schools should discriminate against students from private schools, higher social classes or medical families. Rather, Burke and McManus have called for selectors to engage in what they describe as ‘critical reflexivity,’ in which selectors are encouraged to ‘‘interrogate the ways that their decisions might be shaped by exclusive values and perspectives, which profoundly influence how candidates are (or are not) recognized as having talent, ability and potential,’’ (Burke and McManus 2011; p. 710). For example, selectors might consider the ways in which capital influences a candidate’s ability to demonstrate insight and understanding of a medical career and whether this is a necessary precursor to success on a medical programme. Furthermore, fair access and widening participation initiatives will be ineffective if they continue to focus on the ways in which individuals from traditionally under-represented groups must change to fit with institutionalised conceptualisations of potential (Archer et al. 2003; Burke and McManus 2011). This approach reinforces the legitimacy of activities accessible to those with the most capital and emphasises the perceived deficits of those without (Burke and McManus 2011); allowing activities exclusive to students in private education or from medical families to drive selector expectations. Programmes to promote fair access to work experience are gaining traction in the UK (Hunter et al. 2010; Stratton 2011). However, if work experience becomes accessible to the majority, it will likely be replaced by a new marker of distinction, such as work experience with increased prestige like witnessing surgery or conducting work experience abroad (Bourdieu 1984). This phenomenon is summarized by Bourdieu: ‘‘The dialectic of downclassing and upclassing which underlies a whole set of social processes presupposes and entails that all the groups concerned run in the same direction, toward the same objectives, the same properties, those which are designated by the leading group and which, by definition are unavailable to the groups following, since, whatever these properties may be intrinsically, they are modified and qualified by their distinctive rarity and will no longer be what they are once they are multiplied and made available to groups lower down (Bourdieu 1984; p. 25).’’

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The personal statement provides the perfect vehicle for communicating these cultural privileges, which are being misrecognised as student potential for university study (Burke and McManus 2011; Jones 2012; Turner and Nicholson 2011). This phenomenon can also be seen in extracurricular activities now often listed in personal statements such as playing a musical instrument, completing a Duke of Edinburgh award, participating in sports or attending costly medical introductory courses such as Medlink. As a result, selectors may now expect to see such activities, and may question the commitment and motivation of applicants without them, despite having little evidence to suggest they make a difference in medical school performance. While work experience and extracurricular activities are becoming more common on personal statements, such activities are limited to those with social connections to gain access, and those who can afford to participate (Mangan 2008; Stephenson and Stephenson 2010). Redefine institutional excellence Widening participation initiatives seek to address the inequalities identified in the current study along with improving attainment and aspirations of underrepresented groups. However, these initiatives inevitably identify such groups through their perceived deficits compared to traditional higher education entrants (Burke and McManus 2011). Rhetoric has become increasingly hostile in the media and among academics, with regard to attempts at addressing educational inequalities during the selection process. Critics assert that widening participation initiatives are tantamount to positive discrimination, social engineering and a threat to educational standards (Charlton 2008; Henry 2012; Ip and McManus 2008; Woods 2012). These arguments construct students as being inherently suitable or unsuitable for university study, reinforcing a false dichotomy between a diverse student body and institutional excellence (Burke and McManus 2011). The current study suggests that access to social, cultural and economic capital are likely to provide advantage during the selection process; however, other studies suggest capital has little effect on undergraduate examination performance and degree outcomes (HEFCE 2005; Kirkup et al. 2010; Ogg et al. 2009; Wright and Bradley 2010). Portraying diversity as a threat to standards also increases uncertainty and competition amongst those who selfidentify as suitable university candidates; perhaps providing some insight into the reported extreme lengths to which schools and individuals were willing to go in order to secure a university place. Other instances of dishonest practices build an unflattering picture of fierce competition for university places, in which schools engaged with the field of university admissions hold a clear advantage. For example, A level examination board members were recently caught providing examination details to teachers eager to coach their students in exchange for money (Watt et al. 2011). These behaviours run counter to the professional behaviour and values expected of medical students when they enter medical school (GMC and MSC 2009). Medical schools are unwittingly complicit in this aggressive system by neglecting to examine how their selection methods favour students who are culturally aligned with traditional concepts of a ‘good’ student. If fair access and social mobility are truly the goal, universities need to redefine institutional excellence to include values such as diversity, equality and social accountability; this can be achieved by building such values into the institutional ethos and considering ways these values can be emphasised during the admissions process (Burke and McManus 2011; Razack et al. 2012).

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Engage with education policy This study also emphasises the need for universities to keep selectors informed regarding education policy changes, which will undoubtedly have an effect on university applications. The current study took place before the enforcement of the Education Act 2011, which has since devolved all responsibility for the delivery of careers advice to schools (Careers England 2012). While the Act provides clarity on the school’s responsibility in providing careers advice to students, a recent survey suggests that state schools are unprepared and ill equipped for this new role (Careers England 2012), yielding grave concerns that careers services in state schools have deteriorated further since the time of the current study (House of Commons Education Committee 2013). State schools are now expected to deliver careers advice to students with no additional, and in some cases reduced funding, which is likely to exacerbate, rather than alleviate pre-existing inequalities (Milburn 2012; Sharp 2011). Previous policies recognised the inequalities in careers advice provision in schools, resulting in schemes designed to help bridge this gap, such as Connexions (which offered young people careers advice outside of school), and Aim Higher (a national initiative designed to widen participation in higher education through raising aspirations of students from disadvantaged social groups). However, both programmes have recently been abolished by the Coalition government (Harrison 2012; Williams 2011), leaving students from schools and families unfamiliar with higher education with even less support than was available at the time of this study. This is important information for admissions policy decision makers as well as selectors to be aware of, as it has a directly impacts the validity of selection tools such as the personal statement. Whilst the Coalition government has placed increasing pressure on universities to widen participation and promote social mobility, their own policies have created significant barriers in doing so. For example, the pool of eligible applicants may dwindle as the effects of policy changes take effect. The removal of the Education Maintenance Allowance, which provided financial support to students struggling to afford secondary education will arguably reduce the proportion of lower income students who are able to complete A levels; a key prerequisite for university study (Evans 2012). Changes to the funding structure of UK higher education have led to tuition fee caps being raised from £3,000 to £9,000 per year, providing a significant financial barrier to students contemplating higher education (Barr 2012). While fees are not charged up front and student loans and bursaries are available, disadvantaged groups are the least likely to access good information about the financial support available, may under-estimate the benefits of a university education and are more risk averse (Barr 2012). Universities need to engage the government in debate regarding the effects of such policy changes if diversity is truly the goal. Acknowledgments The author would like to thank the participants of the study for their time and honesty. She would also like to thank Professor Robin Humphrey, Professor Philip Bradley and Dr. Robin Henderson for their support and guidance throughout the study and Dr. Caragh Brosnan, Dr. Saleem Razack and Dr. Jan Deckers for their insightful comments on the manuscript.

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