Widening access to medicine: A realist review

The under-participation of students from disadvantaged population groups in medical education reflects broader complex structural and societal issues, highlighting that widening access (WA) selection pathways into medicine are highly context dependent. While much literature on WA pathways exists, to date this is limited to small, mostly descriptive, single-site studies; hence there is a need for more robust and theory-driven approaches to yield transferable findings. This realist review sought to develop explanatory theory on designing and implementing selection pathways that successfully widen access to medicine and increase cohort diversity.
A realist approach to evidence synthesis identified the mechanisms (M) of action underpinning WA interventions for selection into medical school. We examined how these mechanisms triggered outcomes (O) related to increasing cohort diversity within different contexts (C). Our research design was informed by Pawson’s five iterative strategies for realist review: (1) locate existing theories, (2) search for evidence, (3) select articles, (4) extract and organise data and (5) synthesise the evidence and draw conclusions.
Of the 6300 studies identified and screened in the main search, 32 met the inclusion criteria. Five types of WA interventions were reported across the 32 papers:
(1) Minimising Bias
(2) Modifying selection criteria
(3) Collaborating with community
(4) Preparing applicants for selection and studying medicine
(5) Combining College with Medical School

Our realist analysis developed and refined 19 context-intervention-mechanism-outcome (CIMO) configurations. Mechanisms were categorised as addressing institutional, situational, or dispositional barriers to selection into medicine. While situational factors were often the impetus for implementing a WA intervention, the interventions themselves were developed with either an institutional or dispositional focus.
There are several known situational barriers that influence the decision of individuals from under-represented minority groups just to apply to medical school. The reviewed studies reported on interventions that demonstrated positive gains in increasing applicants, offers and matriculants in several under-represented populations. More research is needed around mitigating barriers earlier in the journey to medical school (pre-application) through to supportive interventions provided once accepted (post-admission, retention, and graduation) to fully diversify the health workforce.
This review highlights how institutions all use demographic characteristics to identify under-represented students, but these demographics are usually blunt one-dimensional measures of disadvantage and therefore limited. This review highlights how sociocultural conditions and policy, either external or within an institution, will drive the commitment and resources made available for a WA intervention. Based on the findings of the review reported here, the review team were left wondering if the interventions being applied are genuinely widening access for disadvantaged applicants to medical education.