Widening access to medicine: A realist review Journal: Medical Education

While medical school selection research has largely focused on the validity of tools and processes, less attention has been paid to the quality and impact of widening access (WA) pathways. Existing studies are often limited in scope, focusing on single institutions or interventions. This study aimed to develop transferable insights into WA selection practices through a realist evaluation across four Australian medical schools.
Methods
Building on a prior realist review, we employed the RAMSES II protocol to explore how contextual factors and mechanisms interact to influence WA outcomes through case studies at four medical schools. Data collection included institutional document and website reviews, semi-structured interviews and focus groups with 41 staff and 17 first-year students. The evaluation framework examined Context (diversity within sociocultural settings), Interventions (targeted pathways, adjusted selection scores), Mechanisms (institutional, dispositional, situational), and Outcomes (applicant diversity, selection success).
Results
Two key interventions were identified as successful across all sites: (1) targeted pathways with selection score adjustments for under-represented groups (e.g., Indigenous, rural, low socio-economic backgrounds), and (2) sustained partnerships with these communities to raise awareness of medicine as a viable career. These partnerships aimed to enhance applicants’ dispositions and readiness for selection.
Discussion
The resulting programme theory identified five main mechanisms underpinning effective WA: visionary leadership, Indigenous cultural safety, longitudinal relational engagement, tailored applicant support, and preparation for selection processes. While demographic shifts, particularly in rural and Indigenous representation, were observed over a 12-year period, the scope of WA remains narrow. Structural changes within institutions pose significant risks to the sustainability of these efforts.
Conclusion
We argue for a national, coordinated approach to WA in medical education, underpinned by long-term investment, robust evaluation, and a broader conceptualisation of equity in access. WA must be embedded as a core institutional commitment rather than a peripheral initiative.