The elusive grail of social inclusion in medical selection

In this issue, a study by O'Neill and colleagues reports that the social composition of Danish medical students was similar whether they were selected according to school-leaving grades or on an ‘attribute-based’ track.1 The latter was designed to afford students whose academic grades may have been limited by socio-economic disadvantage, a chance of entry on the basis of ‘other valuable qualifications and attributes’.1 These results point to the difficulty of designing merit-based programmes of assessment for medical school entry which compensate for social, and consequently educational, disadvantage. Without knowing the social demographics of the unsuccessful applicants in this study, it is difficult to say whether initiatives should now focus on attracting a ‘sufficiently diverse applicant pool’, as favoured by O'Neill and colleagues,1 or on attempting to improve selection assessments. Alternatively, if the arguments for a social inclusion agenda are strong enough, there may be a case for imposing a direct quota system similar to those used elsewhere to increase indigenous or rural student numbers.2, 3 Are the arguments sufficiently strong? The 2010 Ottawa Conference Consensus Statement on selection for the health care professions argued that wider social and cultural inclusion to reflect the patient populations to be served has a ‘political’ validity in that under-representation is tantamount to discrimination.4 This argument for equity is accompanied by other equity-related concerns, including the proposition that therapeutic relationships and patient outcomes are strengthened by better ‘matching’ of patients and doctors.5 Furthermore, there is at least some evidence that differences in social class between doctors and patients underlie difficulties in communication and the delivery of inferior treatment to patients of lower socio-economic status.6 Clearly, improving care and outcomes for disadvantaged patients falls within the social accountability agenda of medical schools. However, in increasingly pluralist societies, there are many under-represented and disadvantaged social groups which might reasonably lay claim to inclusion in medical student quotas. A ‘social inclusion agenda’ might become arbitrary or unwieldy, and perhaps both. It should also not be assumed that doctors from disadvantaged backgrounds will be more likely to work with disadvantaged patients. Most of these doctors will themselves shift to a higher socio-economic bracket after medical qualification.6 An alternative to recruiting more medical students from lower socio-economic strata is to train all medical students in cultural and social competence, including effective communication with different social groups.7 As almost all doctors will work with patients from backgrounds which differ from their own at some stage during their careers, this training should be fundamental to all medical school programmes. It should also be noted that medicine is not the only career open to talented young people with a commitment to promoting health and providing health care effectively in disadvantaged communities. A successful social inclusion agenda for medical education is also costly. Medical courses are challenging, and students with lower academic qualifications are more likely to struggle academically and sometimes also socially.8 Deliberate upstream strategies to support students from identified groups to become more competitive at selection,9 as well as targeted academic support programmes during medical school training,10 appear to be successful. However, the costs of pre-medical ‘pipeline’ and special preparation programmes within these comprehensive strategies of recruitment, retention and support in the curriculum are considerable.5 Are there other arguments for the social inclusion agenda? There is also the suggestion that greater diversity in student cohorts is likely to produce a socially and intellectually richer educational environment in which traditional, potentially harmful paradigms of medical culture are more likely to be challenged. This argument is also intuitively compelling and probably irrefutable. However, there may be other, more cost-effective strategies for addressing the harmful institutional structures, hierarchical relationships and ethical lapses that have been identified as comprising a pervasive hidden curriculum in medical education. The stakes are high for medical applicants and their families, and any selection process will both attract its share of gaming from applicants and deny admission to some with the potential to become excellent doctors. Medical student selection and training are already expensive and resource-intensive. Quests for plausible but elusive social accountability goals should therefore be reflective, finite and practical. It is incumbent on medical educators to evaluate not only the cost-effectiveness of various social inclusion strategies, including quotas, but also the longer-term consequences of successfully broadening social inclusion. Cohort and other studies may demonstrate benefits, or they may show that, despite its apparent political validity, the quest for social inclusion in medical selection is impractical, misplaced and unaffordable.