Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis

Factors predicting success in the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination: a summary for OMFS

The Intercollegiate Membership of the Royal College of Surgeons (MRCS, parts A and B) is a mandatory examination for entry into higher surgical training in the UK. We investigated which factors predict success in both the written (Part A) and clinical (Part B) parts of the examination, and provide a summary for oral and maxillofacial surgeons (OMFS). All UK graduates who attempted both parts between 2007 and 2016 were included. There was a positive correlation between the scores in parts A and B (r=0.41, p<0.01). For Part A, men (odds ratio (OR) 2.78; 95% CI 1.83 to 4.19), white candidates (OR 1.70; 95% CI 1.52 to 1.89), and younger graduates (under 29years of age), were more likely to pass (OR 2.60; 95% CI 1.81 to 3.63). Foundation year one (FY1) doctors had higher pass rates than all other grades (e.g. core surgical trainee 2 compared with FY1 OR 0.50; 95% CI 0.32 to 0.77). The number of attempts at Part A and the final score, as well as ethnicity and stage of training, were independent predictors of success in Part B. Candidates who did well in Part A were more likely to do well in Part B. Several independent predictors of success were identified, but only the stage of training and ethnicity were common predictors in both parts. Higher scores obtained by younger candidates might be relevant to OMFS trainees who take Part A after studying medicine as a second degree.

Has there been a change in the knowledge of GP registrars between 2011 and 2016 as measured by performance on common items in the Applied Knowledge Test?

The aim of this study was to assess whether the absolute standard of candidates sitting the MRCGP Applied Knowledge Test (AKT) between 2011 and 2016 had changed. It is a descriptive study comparing the performance on marker questions of a reference group of UK graduates taking the AKT for the first time between 2011 and 2016. Using aggregated examination data, the performance of individual 'marker' questions was compared using Pearson's chi-squared tests and trend-line analysis. Binary logistic regression was used to analyse changes in performance over the study period. Changes in performance of individual marker questions using Pearson's chi-squared test showed statistically significant differences in 32 of the 49 questions included in the study. Trend line analysis showed a positive trend in 29 questions and a negative trend in the remaining 23. The magnitude of change was small. Logistic regression did not demonstrate any evidence for a change in the performance of the question set over the study period. However, candidates were more likely to get items on administration wrong compared with clinical medicine or research. There was no evidence of a change in performance of the question set as a whole.

Passing MRCP (UK) PACES: a cross-sectional study examining the performance of doctors by sex and country

BACKGROUND

There is much discussion about the sex differences that exist in medical education. Research from the United Kingdom (UK) and United States has found female doctors earn less, and are less likely to be senior authors on academic papers, but female doctors are also less likely to be sanctioned, and have been found to perform better academically and clinically. It is also known that international medical graduates tend to perform more poorly academically compared to home-trained graduates in the UK, US, and Canada. It is uncertain whether the magnitude and direction of sex differences in doctors' performance is variable by country. We explored the association between doctors' sex and their performance at a large international high-stakes clinical examination: the Membership of the Royal Colleges of Physicians (UK) Practical Assessment of Clinical Examination Skills (PACES). We examined how sex differences varied by the country in which the doctor received their primary medical qualification, the country in which they took the PACES examination, and by the country in which they are registered to practise.

METHODS

Seven thousand six hundred seventy-one doctors attempted PACES between October 2010 and May 2013. We analysed sex differences in first time pass rates, controlling for ethnicity, in three groups: (i) UK medical graduates (N = 3574); (ii) non-UK medical graduates registered with the UK medical regulator, the General Medical Council (GMC), and thus likely to be working in the UK (N = 1067); and (iii) non-UK medical graduates without GMC registration and so legally unable to work or train in the UK (N = 2179).

RESULTS

Female doctors were statistically significantly more likely to pass at their first attempt in all three groups, with the greatest sex effect seen in non-UK medical graduates without GMC registration (OR = 1.99; 95% CI = 1.65-2.39; P < 0.0001) and the smallest in the UK graduates (OR = 1.18; 95% CI = 1.03-1.35; P = 0.02).

CONCLUSIONS

As found in a previous format of this examination and in other clinical examinations, female doctors outperformed male doctors. Further work is required to explore why sex differences were greater in non-UK graduates, especially those without GMC registration, and to consider how examination performance may relate to performance in practice.

Using differential item functioning to evaluate potential bias in a high stakes postgraduate knowledge based assessment

BACKGROUND

Fairness is a critical component of defensible assessment. Candidates should perform according to ability without influence from background characteristics such as ethnicity or sex. However, performance differs by candidate background in many assessment environments. Many potential causes of such differences exist, and examinations must be routinely analysed to ensure they do not present inappropriate progression barriers for any candidate group. By analysing the individual questions of an examination through techniques such as Differential Item Functioning (DIF), we can test whether a subset of unfair questions explains group-level differences. Such items can then be revised or removed.

METHODS

We used DIF to investigate fairness for 13,694 candidates sitting a major international summative postgraduate examination in internal medicine. We compared (a) ethnically white UK graduates against ethnically non-white UK graduates and (b) male UK graduates against female UK graduates. DIF was used to test 2773 questions across 14 sittings.

RESULTS

Across 2773 questions eight (0.29%) showed notable DIF after correcting for multiple comparisons: seven medium effects and one large effect. Blinded analysis of these questions by a panel of clinician assessors identified no plausible explanations for the differences. These questions were removed from the question bank and we present them here to share knowledge of questions with DIF. These questions did not significantly impact the overall performance of the cohort. Group-level differences in performance between the groups we studied in this examination cannot be explained by a subset of unfair questions.

CONCLUSIONS

DIF helps explore fairness in assessment at the question level. This is especially important in high-stakes assessment where a small number of unfair questions may adversely impact the passing rates of some groups. However, very few questions exhibited notable DIF so differences in passing rates for the groups we studied cannot be explained by unfairness at the question level.

Predictors of success in the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination

Introduction The Intercollegiate Membership of the Royal College of Surgeons (MRCS, Parts A and B) is designed to safeguard patients and ensure high standards for trainees wishing to pursue a surgical career. We investigated which factors predict Part A and B success. Methods UK graduates who had attempted both parts of MRCS from September 2007 to February 2016 were included. Pearson correlation coefficients were used to examine the linear relationship between each part of MRCS and logistic regression analysis to identify potential independent predictors of MRCS pass/fail outcome. Results A positive correlation between Part A and B score was identified (r = 0.41, P < 0.01). In Part A, males had higher pass rates than females (odds ratio, OR, 2.78, 95% confidence interval, CI, 1.83-4.19), white candidates were more likely to pass than black minority and ethnic doctors (OR 1.70, 95% CI 1.52-1.89), foundation year 1 doctors had higher pass rates than all other grades (e.g. core surgical year 2 trainees vs. foundation year 1 doctors, OR 0.50, 95% CI 0.32-0.77) and younger graduates were more likely to pass than older graduates (OR 2.60, 95% CI 1.81-3.63). In addition to ethnicity and stage of training, Part A performance (number of attempts and score) was an independent predictor for Part B. Conclusions Part A performance is related to Part B score. Many independent predictors of MRCS success were identified, but only stage of training and ethnicity were found to be common predictors of both parts. This article summarises the findings of our most recent MRCS study which was published in The Surgeon (online) in October 2017. ¹.

Organisational perspectives on addressing differential attainment in postgraduate medical education: a qualitative study in the UK

OBJECTIVES

To explore how representatives from organisations with responsibility for doctors in training perceive risks to the educational progression of UK medical graduates from black and minority ethnic groups (BME UKGs), and graduates of non-UK medical schools (international medical graduates (IMGs)). To identify the barriers to and facilitators of change.

DESIGN

Qualitative semistructured individual and group interview study.

SETTING

Postgraduate medical education in the UK.

PARTICIPANTS

Individuals with roles in examinations and/or curriculum design from UK medical Royal Colleges. Employees of NHS Employers.

RESULTS

Representatives from 11 medical Royal Colleges (n=29) and NHS Employers (n=2) took part (55% medically qualified, 61% male, 71% white British/Irish, 23% Asian/Asian British, 6% missing ethnicity). Risks were perceived as significant, although more so for IMGs than for BME UKGs. Participants based significance ratings on evidence obtained largely through personal experience. A lack of evidence led to downgrading of significance. Participants were pessimistic about effecting change, two main barriers being sensitivities around race and the isolation of interventions. Participants felt that organisations should acknowledge problems, but felt concerned about being transparent without a solution; and talking about race with trainees was felt to be difficult. Participants mentioned 63 schemes aiming to address differential attainment, but these were typically local or specialty-specific, were not aimed at BME UKGs and were largely unevaluated. Participants felt that national change was needed, but only felt empowered to effect change locally or within their specialty.

CONCLUSIONS

Representatives from organisations responsible for training doctors perceived the risks faced by BME UKGs and IMGs as significant but difficult to change. Strategies to help organisations address these risks include: increased openness to discussing race (including ethnic differences in attainment among UKGs); better sharing of information and resources nationally to empower organisations to effect change locally and within specialties; and evaluation of evidence-based interventions.

Exploring the ethnic diversity of UK dentistry

This article was migrated. The article was marked as recommended. It is widely acknowledged that there are many social benefits to having a multicultural health force, including ensuring that there is less of a barrier around access for underrepresented groups. Despite this, certain healthcare professions, including dentistry, have struggled with the historical legacy of being conceptualised as a "white" profession and whether it is ethnically representative of the public it serves. This article examines the role and place of ethnicity in the dental profession in the UK. It will describe the changing ethnic composition of UK dentistry and highlight some of the challenges faced by the profession from an equality and diversity perspective. The current qualitative work of the author exploring the barriers and facilitators faced by students from an ethnic background pursuing a career in dentistry will also be introduced. It concludes by encouraging more research on this topic.

The MRCGP Clinical Skills Assessment: an integrative review of evidence

Background Successful completion of all three components of the Membership of the Royal College of General Practitioners UK (MRCGP) is required for a doctor to practise independently as a general practitioner (GP). One component, the Clinical Skills Assessment (CSA), is a high fidelity, high stakes examination designed to provide an objective external assessment of clinical skills. Aim The aim of this integrative review was to identify, critically appraise and synthesise published empirical evidence on the CSA to identify areas for further inquiry or future collaboration. Design and setting An integrative review of empirical literature focused on the MRCGP CSA. Method A search strategy was developed to conduct an integrative review of empirical published literature. The quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). Results 11 of the 31 records reviewed were included. Studies were heterogeneous looking at the use of simulated patients, child actors and mock CSAs. Variables contributing to performance on the CSA, with a particular emphasis on the International Medical Graduate, were identified. Conclusion A small pool of published evidence regarding the CSA exists, focused on factors influencing CSA performance. Future research could explore the effectiveness of interventions to improve performance on the CSA and use robust measures to consider candidates' experience of the CSA.

Performance of candidates disclosing dyslexia with other candidates in a UK medical licensing examination: cross-sectional study

Purpose of the study

The aim of this study was to compare performance of candidates who declared an expert-confirmed diagnosis of dyslexia with all other candidates in the Applied Knowledge Test (AKT) of the Membership of the Royal College of General Practitioners licensing examination.

Study design

We used routinely collected data from candidates who took the AKT on one or more occasions between 2010 and 2015. Multivariate logistic regression was used to analyse performance of candidates who declared dyslexia with all other candidates, adjusting for candidate characteristics known to be associated with examination success including age, sex, ethnicity, country of primary medical qualification, stage of training, number of attempts and time spent completing the test.

Results

The analysis included data from 14 examinations involving 14 801 candidates of which 2.6% (379/14 801) declared dyslexia. The pass rate for candidates who declared dyslexia was 83.6% compared with 95.0% for other candidates. After adjusting for covariates linked to examination success including age, sex, ethnicity, country of primary medical qualification, stage of training, number of attempts and time spent completing the test dyslexia was not significantly associated with pass rates in the AKT. Candidates declaring dyslexia after initially failing the AKT were more likely to have a primary medical qualification outside the UK.

Conclusions

Performance was similar in AKT candidates disclosing dyslexia with other candidates once covariates associated with examination success were adjusted for. Candidates declaring dyslexia after initially failing the AKT were more likely to have a primary medical qualification outside the UK.

Motivation and academic performance of medical students from ethnic minorities and majority: a comparative study

BACKGROUND

Medical students from ethnic minorities underperform in knowledge and skills assessments both in pre-clinical and clinical education compared to the ethnic majority group. Motivation, which influences learning and academic performance of medical students, might play an important role in explaining these differences, but is under-investigated. This study aimed to compare two types of motivation (autonomous and controlled) of ethnic minority (Western and non-Western) and majority (Dutch) students, and their association with academic performance.

METHODS

In a cross-sectional study, all students of a Dutch medical school were invited to complete a survey including the Academic Self-Regulation Questionnaire, measuring autonomous and controlled motivation, in the academic year 2015-2016. Motivation was compared using Kruskal-Wallis test and performance was compared using One-Way ANOVA. Linear regression analysis was used to determine the association between motivation and performance (grade point average; GPA).

RESULTS

The response rate was 38.6% (n = 947). Autonomous motivation (AM) of non-Western students was higher than that of Dutch students in pre-clinical and clinical education (p < 0.05). Controlled motivation was higher in Western students than in Dutch students (pre-clinical education; p < 0.05). AM was associated with a higher GPA for Dutch (pre-clinical education; β = 0.33, p < 0.05) and Western students (clinical education; β = 0.57, p < 0.05) only.

CONCLUSIONS

Our results show significant differences in the type of motivation between the ethnic majority and minority groups. The association of motivation with performance also differs between ethnic groups. We found that AM has a positive influence on GPA. Further research is needed to uncover the underlying mechanisms.

Individual student characteristics and attainment in pre registration physiotherapy: a retrospective multi site cohort study

INTRODUCTION

Worldwide there is a desire to diversify the physiotherapy workforce. However, limited research indicates that some student characteristics linked to under-representation in pre registration physiotherapy education have lower attainment and greater attrition. This study explored the relationship between individual characteristics and success of students in pre registration physiotherapy education within South East England.

DESIGN

A retrospective multi site cohort study including pre registration physiotherapy programmes in the South East of England. Anonymised data included background information (age, gender, ethnicity, socio-economic status) and outcomes (assessment marks, type of award and classification of degree). Analysis involved Bayesian regression models and ordinal logistic regression to examine the association of student characteristics on outcomes.

RESULTS

Data from 1851 student records were collected from four institutions. There were significantly lower assessment scores for Asian (-11% 95% CI: -13.1 to -9.2), Black (-7%, 95% CI: -9.7 to -4.5) and Other/Mixed ethnicity groups (-5%, 95% CI: -7.1 to -2.4), most notable in clinical and observed assessments, compared to their White British colleagues. All BME groups also demonstrated worse odds for a one step lower overall award or no award (Black OR: 3.35, Asian OR: 3.97, Other OR: 2.03). Associations of learning disability, age and non-traditional entry routes with assessment scores and/or degree classification were also noted.

CONCLUSION

These findings suggest significant attainment gaps in pre registration physiotherapy education in this specific geographical region, particularly for non-White ethnic and disability groups. The association with assessment type challenges educators to look beyond a purely student deficit model to explore all factors that may lead to inequality.

Is it them or is it us? Unravelling ethnic disparities in undergraduate clinical performance

Given our increasingly diverse societies, there is an urgent need for research into the causes of persistent ethnic disparities in undergraduate clinical performance. It is argued that causes for underperformance can be identified from two perspectives, namely that of the students ('them') and that of the academic environment ('us'). Taking the 'us' perspective, Yeates et al. conducted a detailed experimental study aimed at understanding the processes underlying judgment and decision-making in clinical assessments. Contrary to their expectations, their study indicates that, despite the presence of active stereotypes, examiner bias does not explain ethnic minority students' underperformance. Naturally, future studies are required to confirm their findings. It is suggested that these studies should take into account various rater and situational factors (e.g. rater experience, increased cognitive load) that may influence examiners' reliance on stereotypes. However, future work should also focus on other potential impeding factors from both perspectives, including differences in communication styles. Knowing what leads to the ethnic disparities in performance is a prerequisite for designing interventions aimed at ensuring a level playing field for a diverse student population.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0943-0.

A randomised trial of the influence of racial stereotype bias on examiners' scores, feedback and recollections in undergraduate clinical exams

BACKGROUND

Asian medical students and doctors receive lower scores on average than their white counterparts in examinations in the UK and internationally (a phenomenon known as "differential attainment"). This could be due to examiner bias or to social, psychological or cultural influences on learning or performance. We investigated whether students' scores or feedback show influence of ethnicity-related bias; whether examiners unconsciously bring to mind (activate) stereotypes when judging Asian students' performance; whether activation depends on the stereotypicality of students' performances; and whether stereotypes influence examiner memories of performances.

METHODS

This is a randomised, double-blinded, controlled, Internet-based trial. We created near-identical videos of medical student performances on a simulated Objective Structured Clinical Exam using British Asian and white British actors. Examiners were randomly assigned to watch performances from white and Asian students that were either consistent or inconsistent with a previously described stereotype of Asian students' performance. We compared the two examiner groups in terms of the following: the scores and feedback they gave white and Asian students; how much the Asian stereotype was activated in their minds (response times to Asian-stereotypical vs neutral words in a lexical decision task); and whether the stereotype influenced memories of student performances (recognition rates for real vs invented stereotype-consistent vs stereotype-inconsistent phrases from one of the videos).

RESULTS

Examiners responded to Asian-stereotypical words (716 ms, 95% confidence interval (CI) 702-731 ms) faster than neutral words (769 ms, 95% CI 753-786 ms, p < 0.001), suggesting Asian stereotypes were activated (or at least active) in examiners' minds. This occurred regardless of whether examiners observed stereotype-consistent or stereotype-inconsistent performances. Despite this stereotype activation, student ethnicity had no influence on examiners' scores; on the feedback examiners gave; or on examiners' memories for one performance.

CONCLUSIONS

Examiner bias does not appear to explain the differential attainment of Asian students in UK medical schools. Efforts to ensure equality should focus on social, psychological and cultural factors that may disadvantage learning or performance in Asian and other minority ethnic students.

The relationship between school type and academic performance at medical school: a national, multi-cohort study

OBJECTIVES

Differential attainment in school examinations is one of the barriers to increasing student diversity in medicine. However, studies on the predictive validity of prior academic achievement and educational performance at medical school are contradictory, possibly due to single-site studies or studies which focus only on early years' performance. To address these gaps, we examined the relationship between sociodemographic factors, including school type and average educational performance throughout medical school across a large number of diverse medical programmes.

METHODS

This retrospective study analysed data from students who graduated from 33 UK medical schools between 2012 and 2013. We included candidates' demographics, pre-entry grades (adjusted Universities and Colleges Admissions Service tariff scores) preadmission test scores (UK Clinical Aptitude Test (UKCAT) and Graduate Medical School Admissions Test (GAMSAT)) and used the UK Foundation Programme's educational performance measure (EPM) decile as an outcome measure. Logistic regression was used to assess the independent relationship between students' background characteristics and EPM ranking.

RESULTS

Students from independent schools had significantly higher mean UKCAT scores (2535.1, SD=209.6) than students from state-funded schools (2506.1, SD=224.0, p<0.001). Similarly, students from independent schools came into medical school with significantly higher mean GAMSAT scores (63.9, SD=6.9) than students from state-funded schools (60.8, SD=7.1, p<0.001). However, students from state-funded schools were almost twice as likely (OR=2.01, 95% CI 1.49 to 2.73) to finish in the highest rank of the EPM ranking than those who attended independent schools.

CONCLUSIONS

This is the first large-scale study to examine directly the relationship between school type and overall performance at medical school. Our findings provide modest supportive evidence that, when students from independent and state schools enter with similar pre-entry grades, once in medical school, students from state-funded schools are likely to outperform students from independent schools. This evidence contributes to discussions around contextualising medical admission.

Using a situational judgement test for selection into dental core training: a preliminary analysis

Objective and setting This paper describes the evaluation of a pilot situational judgement test (SJT) for selection into UK Dental Core Training (DCT). The SJT's psychometric properties, group differences based on gender and ethnicity, and candidate reactions were assessed.Methods The SJT targets four non-academic attributes important for success in DCT. Data were collected alongside live selection processes from five Health Education England local teams in the UK (N = 386). Candidates completed the pilot SJT and an evaluation questionnaire to examine their reactions to the test.Results SJT scores were relatively normally distributed and showed acceptable levels of internal reliability (α = 0.68). Difficulty level and partial correlations between scenarios and SJT total score were in the expected ranges (64.61% to 90.03% and r = 0.06 to 0.41, respectively). No group differences were found for gender, and group differences between White and BME candidates were minimal. Most candidates perceived the SJT as relevant to the target role, appropriate and fair.Conclusions This study demonstrated the potential suitability of an SJT for use in DCT selection. Future research should replicate these preliminary findings in other cohorts, and assess the predictive validity of the SJT for predicting key training and practice-based outcomes.

Cultural minority students' experiences with intercultural competency in medical education

CONTEXT

Medical schools increasingly value and focus on teaching students intercultural competency within present-day multicultural society. Little is known about the experiences of cultural minority students in intercultural competence activities.

OBJECTIVES

This article discusses the intercultural competence activities of medical education in a Dutch university from the perspective of cultural minority students. We will formulate recommendations for how to stimulate intercultural competency in, as well as inclusiveness of, medical education.

METHODS

A qualitative evaluation was performed within a medical school in the Netherlands. Data were collected through interviews (n = 23), a focus group (six participants) and participant observations (20 hours). Thematic analysis was performed.

RESULTS

Cultural minority students experienced a lack of respect and understanding by cultural majority students and teachers. Education activities intended to transfer intercultural knowledge, address personal prejudice and stimulate intercultural sensitivity were perceived as stigmatising and as creating an unsafe climate for cultural minority students. Cultural minority and majority students on campus seemed segregated and the intercultural awareness of minority students was not integrated in intercultural competence activities.

CONCLUSIONS

As cultural minority students were confronted with microaggressions, the medical school did not succeed in creating a safe education environment for all students. Contrary to their aims and intentions, intercultural competence activities had limited effect and seemed to support the polarisation of cultural minority and majority students and teachers. This can be seen as pointing towards a hidden curriculum privileging majority over minority students. For structural integration of intercultural competency in medical education, the focus must penetrate beyond curricular activities towards the critical addressing of the culture and structure of medical school. Collective commitment to creating a safe and inclusive education climate is vital. This requires fostering social cohesion between minority and majority students and teachers, raising awareness and the practice by all involved of critical (self-)reflexivity on cultural prejudice and dominant, exclusionary norms in academic medicine.

Identifying factors that predict attrition among first year physiotherapy students: a retrospective analysis

BACKGROUND

A number of first year students leave physiotherapy programmes every year. A high attrition rate has implications for the student and the academic institution.

OBJECTIVES

To report the rate of attrition among first year physiotherapy students, and to identify contributing factor.

DESIGN

Retrospective analysis.

SETTING

University.

PARTICIPANTS

Electronic student records for enrolled students 2010 to 2013.

MEASURES

Independent variables; gender, age at entry, mode of admission, place of residence, ethnicity, fee status, level of education, disability, whether a student obtained a B in A level Biology, and whether a student repeated A level examinations. Logistic regression analysis was conducted to identify the relationship between independent variables and drop-out (failure to continue to the second year).

RESULTS

Data from 338 students were included in the analysis. The percentage drop-out was 17%; 38 students (11%) failed, and 20 students (6%) withdrew voluntarily. Black and Asian students had greater odds of drop-out for any reason (Odds Ratio (OR): 6.23; 95% Confidence Interval (CI) 1.79 to 21.63, and OR: 6.43; 95% CI: 3.03 to 13.68 respectively), and due to failure (OR: 5.50, 95% CI: 1.27 to 23.70, and OR: 7.19; 95% CI: 3.02 to 17.08, respectively) compared to white British students. Students who lived off-campus were more likely to withdraw from the programme irrespective of ethnicity (OR: 4.65; 95% CI: 1.41 to 15.34).

CONCLUSION

A significant number of students from ethnic minority backgrounds failed to progress. Specific strategies to retain students from ethnic minority backgrounds should be implemented. Students who live off-campus may be at high risk of drop-out; reasons for this should be investigated.

Sociolinguistic factors affecting performance in the Clinical Skills Assessment of the MRCGP: a mixed-methods approach

Background

Differential performance in clinical skills assessments is a widespread phenomenon, for which there remain few explanations.

Aim

To better understand the conversational contexts of simulated consultations and how candidates actually behave in these consultations and to determine sociolinguistic factors for high- and low-performing candidates.

Design & setting

Taking the Membership of the Royal College of General Practitioners' (MRCGP) clinical skills assessment (CSA) examination as a model, this research applied sociolinguistic analyses to case videos of 198 consecutive candidates presenting for the CSA examination.

Method

Using a mixed-methods approach, both quantitative and qualitative sociolinguistics methodologies were combined to analyse video consultations, and findings were compared with those from group discussions with MRCGP examiners.

Results

There is more ‘talk’ in simulated consultations than in real life. On macroanalysis, there was little difference between poor- and well-performing candidates. However, microanalysis found subtle differences in structuring consultations, metacommunication, picking up cues, and misunderstandings with and giving explanations to patients. Formulaic talk, contrary to examiners’ perceptions was more common in successful candidates, but it was personalised and sited appropriately in the consultation.

Conclusion

This is an interactionally demanding form of clinical assessment, that requires giving support to candidates and a more analytic approach to the development of interpersonal skills. Sociolinguistic features of consulting to help trainers and candidates prepare for the CSA are identified.

'You can't be a person and a doctor': the work-life balance of doctors in training-a qualitative study

OBJECTIVES

Investigate the work-life balance of doctors in training in the UK from the perspectives of trainers and trainees.

DESIGN

Qualitative semistructured focus groups and interviews with trainees and trainers.

SETTING

Postgraduate medical training in London, Yorkshire and Humber, Kent, Surrey and Sussex, and Wales during the junior doctor contract dispute at the end of 2015. Part of a larger General Medical Council study about the fairness of postgraduate medical training.

PARTICIPANTS

96 trainees and 41 trainers. Trainees comprised UK graduates and International Medical Graduates, across all stages of training in 6 specialties (General Practice, Medicine, Obstetrics and Gynaecology, Psychiatry, Radiology, Surgery) and Foundation.

RESULTS

Postgraduate training was characterised by work-life imbalance. Long hours at work were typically supplemented with revision and completion of the e-portfolio. Trainees regularly moved workplaces which could disrupt their personal lives and sometimes led to separation from friends and family. This made it challenging to cope with personal pressures, the stresses of which could then impinge on learning and training, while also leaving trainees with a lack of social support outside work to buffer against the considerable stresses of training. Low morale and harm to well-being resulted in some trainees feeling dehumanised. Work-life imbalance was particularly severe for those with children and especially women who faced a lack of less-than-full-time positions and discriminatory attitudes. Female trainees frequently talked about having to choose a specialty they felt was more conducive to a work-life balance such as General Practice. The proposed junior doctor contract was felt to exacerbate existing problems.

CONCLUSIONS

A lack of work-life balance in postgraduate medical training negatively impacted on trainees' learning and well-being. Women with children were particularly affected, suggesting this group would benefit the greatest from changes to improve the work-life balance of trainees.

Ethnic and social disparities in different types of examinations in undergraduate pre-clinical training

Medical schools are increasingly faced with a more diverse student population. Generally, ethnic minority students are reported to underperform compared with those from the ethnic majority. However, there are inconsistencies in findings in different types of examinations. Additionally, little is known about the performance of first-generation university students and about performance differences across ethnic minority groups. This study aimed to investigate underperformance across ethnic minority groups and by first-generation university students in different types of written tests and clinical skills examinations during pre-clinical training. A longitudinal prospective cohort study of progress on a 3-year Dutch Bachelor of Medicine course was conducted. Participants included 2432 students who entered the course over a consecutive 6-year period (2008-2013). Compared with Dutch students, the three non-Western ethnic minority groups (Turkish/Moroccan/African, Surinamese/Antillean and Asian) underperformed in the clinical problem solving tests, the language test and the OSCEs. Findings on the theoretical end-of-block tests and writing skills tests, and results for Western minority students were less consistent. Age, gender, pre-university grade point average and additional socio-demographic variables (including first-generation university student, first language, and medical doctor parent) could explain the ethnicity-related differences in theoretical examinations, but not in language, clinical and writing skills examinations. First-generation university students only underperformed in the language test. Apparently, underperformance differs both across ethnic subgroups and between different types of written and clinical examinations. Medical schools should ensure their assessment strategies create a level playing field for all students and explore reasons for underperformance in the clinical and writing skills examinations.

Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study

OBJECTIVES

Explore trainee doctors' experiences of postgraduate training and perceptions of fairness in relation to ethnicity and country of primary medical qualification.

DESIGN

Qualitative semistructured focus group and interview study.

SETTING

Postgraduate training in England (London, Yorkshire and Humber, Kent Surrey and Sussex) and Wales.

PARTICIPANTS

137 participants (96 trainees, 41 trainers) were purposively sampled from a framework comprising: doctors from all stages of training in general practice, medicine, obstetrics and gynaecology, psychiatry, radiology, surgery or foundation, in 4 geographical areas, from white and black and minority ethnic (BME) backgrounds, who qualified in the UK and abroad.

RESULTS

Most trainees described difficult experiences, but BME UK graduates (UKGs) and international medical graduates (IMGs) could face additional difficulties that affected their learning and performance. Relationships with senior doctors were crucial to learning but bias was perceived to make these relationships more problematic for BME UKGs and IMGs. IMGs also had to deal with cultural differences and lack of trust from seniors, often looking to IMG peers for support instead. Workplace-based assessment and recruitment were considered vulnerable to bias whereas examinations were typically considered more rigorous. In a system where success in recruitment and assessments determines where in the country you can get a job, and where work-life balance is often poor, UK BME and international graduates in our sample were more likely to face separation from family and support outside of work, and reported more stress, anxiety or burnout that hindered their learning and performance. A culture in which difficulties are a sign of weakness made seeking support and additional training stigmatising.

CONCLUSIONS

BME UKGs and IMGs can face additional difficulties in training which may impede learning and performance. Non-stigmatising interventions should focus on trainee-trainer relationships at work and organisational changes to improve trainees' ability to seek social support outside work.

Does the UKCAT predict performance on exit from medical school? A national cohort study

OBJECTIVES

Most UK medical programmes use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the UK Clinical Aptitude Test (UKCAT: http://www.ukcat.ac.uk), and 4 of its subscales, along with individual and contextual socioeconomic background factors, as predictors of performance during, and on exit from, medical school.

METHODS

This was an observational study of 6294 medical students from 30 UK medical programmes who took the UKCAT from 2006 to 2008, for whom selection data from the UK Foundation Programme (UKFPO), the next stage of UK medical education training, were available in 2013. We included candidate demographics, UKCAT (cognitive domains; total scores), UKFPO Educational Performance Measure (EPM) and national exit situational judgement test (SJT). Multilevel modelling was used to assess relationships between variables, adjusting for confounders.

RESULTS

The UKCAT-as a total score and in terms of the subtest scores-has significant predictive validity for performance on the UKFPO EPM and SJT. UKFPO performance was also affected positively by female gender, maturity, white ethnicity and coming from a higher social class area at the time of application to medical school An inverse pattern was seen for a contextual measure of school, with those attending fee-paying schools performing significantly more weakly on the EPM decile, the EPM total and the total UKFPO score, but not the SJT, than those attending other types of school.

CONCLUSIONS

This large-scale study, the first to link 2 national databases-UKCAT and UKFPO, has shown that UKCAT is a predictor of medical school outcome. The data provide modest supportive evidence for the UKCAT's role in student selection. The conflicting relationships of socioeconomic contextual measures (area and school) with outcome adds to wider debates about the limitations of these measures, and indicates the need for further research.

A systematic review of assessment and intervention strategies for effective clinical communication in culturally and linguistically diverse students

OBJECTIVE

Culturally and linguistically diverse (CALD) students often experience difficulties with the clinical communication skills that are essential for successful interactions in the workplace. However, there is little evidence on the effectiveness of assessment and intervention strategies for this population. The two aims of this study were: to evaluate the effectiveness of assessment tools in identifying and describing the clinical communication difficulties of CALD health care students; and to determine whether communication programmes improved their clinical communication skills.

METHODS

Systematic review based on the Cochrane protocol. Articles were identified through a search of established databases using MeSH and key search terms. Studies published in English from 1990 to March 2015 were included if they described assessment strategies or a training programme for communication skills of CALD students. Studies were excluded if they did not describe implementation of a specific assessment or intervention programme. Data were extracted independently by the first author and verified by the second author. Quality was measured by the Best Evidence Medical Education guide and the Educational Interventions Critical Appraisal Tool. The Kirkpatrick hierarchy was used to measure impact. Meta-analysis was not conducted because of the heterogeneity of programme design and outcome measures.

RESULTS

One hundred and twenty-nine articles met the criteria for full text review. Eighty-six articles were excluded. Thirteen articles addressing assessment and 30 articles reporting on communication training programmes were included in this review. Assessment tools used rubrics and rating scales effectively. Intervention studies focused on speech and language skills (n = 20), interpersonal skills (n = 7) and faculty-level support (n = 5). Although 17 studies reported positive findings on student satisfaction, only eight reported improved skills post-training.

CONCLUSIONS

The development of effective assessment and intervention programmes should have an integrated design and include specific outcome measures to increase educational impact.

Predictors of professional placement outcome: cultural background, English speaking and international student status

Placements provide opportunities for students to develop practice skills in professional settings. Learning in placements may be challenging for culturally and linguistically diverse (CALD) students, international students, or those without sufficient English proficiency for professional practice. This study investigated whether these factors, which are hypothesized to influence acculturation, predict poor placement outcome. Placement outcome data were collected for 854 students who completed 2747 placements. Placement outcome was categorized into 'Pass' or 'At risk' categories. Multilevel binomial regression analysis was used to determine whether being CALD, an international student, speaking 'English as an additional language', or a 'Language other than English at home' predicted placement outcome. In multiple multilevel analysis speaking English as an additional language and being an international student were significant predictors of 'at risk' placements, but other variables tested were not. Effect sizes were small indicating untested factors also influenced placement outcome. These results suggest that students' English as an additional language or international student status influences success in placements. The extent of acculturation may explain the differences in placement outcome for the groups tested. This suggests that learning needs for placement may differ for students undertaking more acculturative adjustments. Further research is needed to understand this and to identify placement support strategies.

Exploring cultural and linguistic influences on clinical communication skills: a qualitative study of International Medical Graduates

BACKGROUND

International Medical Graduates (IMGs) are known to perform less well in many postgraduate medical examinations when compared to their UK trained counterparts. This "differential attainment" is observed in both knowledge-based and clinical skills assessments. This study explored the influence of culture and language on IMGs clinical communication skills, in particular, their ability to seek, detect and acknowledge patients' concerns in a high stakes postgraduate clinical skills examination. Hofstede's cultural dimensions framework was used to look at the impact of culture on examination performance.

METHODS

This was a qualitative, interpretative study using thematic content analysis of video-recorded doctor-simulated patient consultations of candidates sitting the MRCP(UK) PACES examination, at a single examination centre in November 2012. The research utilised Hofstede's cultural dimension theory, a framework for comparing cultural factors amongst different nations, to help understand the reasons for failure.

RESULTS

Five key themes accounted for the majority of communication failures in station 2, "history taking" and station 4, "communication skills and ethics" of the MRCP(UK) PACES examination. Two themes, the ability to detect clues and the ability to address concerns, related directly to the overall construct managing patients' concerns. Three other themes were found to impact the whole consultation. These were building relationships, providing structure and explanation and planning.

CONCLUSION

Hofstede's cultural dimensions may help to contextualise some of these observations. In some cultures doctor and patient roles are relatively inflexible: the doctor may convey less information to the patient (higher power distance societies) and give less attention to building rapport (high uncertainty avoidance societies.) This may explain why cues and concerns presented by patients were overlooked in this setting. Understanding cultural differences through Hofstede's cultural dimensions theory can inform the preparation of candidates for high stakes bedside clinical skills examinations and for professional practice.

The value of health professions education: the importance of understanding the learner perspective

The value of health professions education (HPE), with increasing demand for value resultant on financial constraint, has come under increasing scrutiny. An essential aspect for critical consideration is the extent to which the value ascribed by the learner differs from that of the HPE provider, especially in relation to the learning Methods and assessment of the HPE curriculum. The challenge of reconciling the tensions and differing perspectives of the learners and HPE providers can be met through co-production of the curriculum. The focus of the co-production approach is the recognition of the importance of diversity and social justice.

Widening access in selection using situational judgement tests: evidence from the UKCAT

CONTEXT

Widening access promotes student diversity and the appropriate representation of all demographic groups. This study aims to examine diversity-related benefits of the use of situational judgement tests (SJTs) in the UK Clinical Aptitude Test (UKCAT) in terms of three demographic variables: (i) socio-economic status (SES); (ii) ethnicity, and (iii) gender.

METHODS

Outcomes in medical and dental school applicant cohorts for the years 2012 (n = 15 581) and 2013 (n = 15 454) were studied. Applicants' scores on cognitive tests and an SJT were linked to SES (parents' occupational status), ethnicity (White versus Black and other minority ethnic candidates), and gender.

RESULTS

Firstly, the effect size for SES was lower for the SJT (d = 0.13-0.20 in favour of the higher SES group) than it was for the cognitive tests (d = 0.38-0.35). Secondly, effect sizes for ethnicity of the SJT and cognitive tests were similar (d = ~ 0.50 in favour of White candidates). Thirdly, males outperformed females on cognitive tests, whereas the reverse was true for SJTs. When equal weight was given to the SJT and the cognitive tests in the admission decision and when the selection ratio was stringent, simulated scenarios showed that using an SJT in addition to cognitive tests might enable admissions boards to select more students from lower SES backgrounds and more female students.

CONCLUSIONS

The SJT has the potential to appropriately complement cognitive tests in the selection of doctors and dentists. It may also put candidates of lower SES backgrounds at less of a disadvantage and may potentially diversify the student intake. However, use of the SJT applied in this study did not diminish the role of ethnicity. Future research should examine these findings with other SJTs and other tests internationally and scrutinise the causes underlying the role of ethnicity.

Entry characteristics and performance in a Masters module in Tropical Medicine: a 5-year analysis

OBJECTIVES

Postgraduate courses can contribute to better-qualified personnel in resource-limited settings. We aimed to identify how entry characteristics of applicants predict performance in order to provide support measures early.

METHODS

We describe demographic data and end-of-module examination marks of medical doctors who enrolled in a first semester module of two one-year MSc programmes between 2010 and 2014. We used t-tests and one-way anova to compare, and post hoc tests to locate differences of mean marks between categories of entry characteristics in univariate analysis. After exclusion of collinear variables, multiple regression examined the effect of several characteristics in multivariable analysis.

RESULTS

Eighty-nine students (47% male) with a mean age of 32 (SD 6.4) years who received their medical degree in the UK (19%), other European (22%), African (35%) or other countries (24%) attended the 3-months module. Their mean mark was 69.1% (SD 10.9). Medical graduates from UK universities achieved significantly higher mean marks than graduates from other countries. Students' age was significantly negatively correlated with the module mark. In multiple linear regression, place of medical degree (β = -0.44, P < 0.001) and time since graduation (β = -0.28, P = 0.007) were strongest predictors of performance, explaining 32% of the variation of mean marks.

CONCLUSION

Students' performance substantially differs based on their entry criteria in this 1st semester module. Non-UK graduates and mature students might benefit from early support.

Role of students' context in predicting academic performance at a medical school: a retrospective cohort study

OBJECTIVES

This study examines associations between medical students' background characteristics (postcode-based measures of disadvantage, high school attended, sociodemographic characteristics), and academic achievement at a Russell Group University.

DESIGN

Retrospective cohort analysis.

SETTING

Applicants accepted at the University of Liverpool medical school between 2004 and 2006, finalising their studies between 2010 and 2011.

PARTICIPANTS

571 students (with an English home postcode) registered on the full-time Medicine and Surgery programme, who successfully completed their medical degree.

MAIN OUTCOME MEASURES

Final average at year 4 of the medical programme (represented as a percentage).

RESULTS

Entry grades were positively associated with final attainment (p<0.001). Students from high-performing schools entered university with higher qualifications than students from low-performing schools (p<0.001), though these differences did not persist at university. Comprehensive school students entered university with higher grades than independent school students (p<0.01), and attained higher averages at university, though differences were not significant after controlling for multiple effects. Associations between school type and achievement differed between sexes. Females attained higher averages than males at university. Significant academic differences were observed between ethnic groups at entry level and university. Neither of the postcode-based measures of disadvantage predicted significant differences in attainment at school or university.

CONCLUSIONS

The findings of this study suggest that educational attainment at school is a good, albeit imperfect, predictor of academic attainment at medical school. Most attainment differences observed between students either decreased or disappeared during university. Unlike previous studies, independent school students did not enter university with the highest grades, but achieved the lowest attainment at university. Such variations depict how patterns may differ between subjects and higher-education institutions. Findings advocate for further evidence to help guide the implementation of changes in admissions processes and widen participation at medical schools fairly.

The association between trainee demographic factors and self-reported experience: Analysis of General Medical Council National Training Survey 2014 and 2015 data

Objectives

To investigate whether demographic factors are associated with self-reported experience amongst medical trainees in the UK.

Design

Retrospective analysis of survey data.

Setting

General Medical Council (UK) National Training Survey data for 2014 and 2015.

Participants

A total of 105,549 responses were provided from 68,551 participants when no data were removed. After removing data to preserve participant anonymity, there were 64,278 participants providing 99,076 responses.

Main outcome measures

Considered trainee factors were gender, ethnicity, country of primary medical qualification, grade, post specialty and deanery. Self-reported outcome measures were ‘overall satisfaction’, ‘adequate experience’, ‘workload’, ‘clinical supervision’, ‘educational supervision’, and ‘access to educational resources’.

Results

The experience of medical trainees across various indicators is differentially related to gender, ethnicity, country of primary medical qualification, grade, post specialty and deanery.

Conclusions

It is demonstrated here that trainee factors are associated with subjective experience across different indicators. Further work is required to explore the reasons behind this, and how this relates to trainee quality of life, work performance and career progression.

Do role-players affect the outcome of a high-stakes postgraduate OSCE, in terms of candidate sex or ethnicity? Results from an analysis of the 52,702 anonymised case scores from one year of the MRCGP clinical skills assessment

The MRCGP clinical skills assessment (CSA), a high-stakes OSCE examination whereby GPs exit their training, uses trained role-players to depict patients (though not to mark candidates). Just as subgroups of examiners can potentially affect the results of subgroups of candidates through biases expressed in discriminatory marking, so possibly could subgroups of role-players alter the difficulty for different candidate groups. This study looks at the contribution of role-players to such possible systematic unfairness in the assessment. Using multiple linear regression, we examined the data from all 52,702 case scores from the MRCGP CSA for the academic year 2012-2013. Candidates were dichotomised by sex, by ethnicity and by source of primary medical qualification (PMQ); role-players were dichotomised by sex and binary ethnicity; and the transaction of candidate/role-player encounters were classified as 'same' or 'different' in terms of the two parties' sex and of their ethnicity. Neither examiner nor role-player characteristics were found to predict any statistically significant portion of case score variance, where the significant (p < .001) predictors were source of PMQ (UK or elsewhere: 11% of case score variance), candidates' ethnicity (1%), candidates' sex (0.6%) and 'transactional' sex (0.1%). We did not therefore find any substantial degree of support for the proposition that role-player subgroups systematically influence candidate subgroups' scores.

Pre-admission criteria and pre-clinical achievement: Can they predict medical students performance in the clinical phase?

RATIONAL

Various factors affect medical students' performance during clinical phase. Identifying these factors would help in mentoring weak students and help in selection process for residency programmes.

OBJECTIVE

Our study objective is to evaluate the impact of pre-admission criteria, and pre-clinical grade point average (GPA) on undergraduate medical students' performance during clinical phase.

METHOD

This study has a cross-sectional design that includes fifth- and sixth-year female medical students (71). Data of clinical and pre-clinical GPA in medical school and pre-admission to medical school tests scores were collected.

RESULTS

A significant correlation between clinical GPA with the pre-clinical GPA was observed (p < 0.05). Such significant correlation was not seen with other variables under study. A regression analysis was performed, and the only significant predictor of students clinical performance was the pre-clinical GPA (p < 0.001). However, no significant difference between students' clinical and pre-clinical GPA for both cohorts was observed (p > 0.05).

CONCLUSION

Pre-clinical GPA is strongly correlated with and can predict medical students' performance during clinical years. Our study highlighted the importance of evaluating the academic performances of students in pre-clinical years before they move into clinical years in order to identify weak students to mentor them and monitor their progress.

Racial and Gender Influences on Pass Rates for the UK and Ireland Specialty Board Examinations

INTRODUCTION

We explored effects of gender, ethnic origin, first language, and training status on scores in the Intercollegiate Specialty Board examinations in the UK and Ireland across the computer-marked written section and in the face-to-face oral and clinical section.

METHODS

Demographic characteristics and examination results from 9987 attempts across 177 sittings from 2009 to 2013 were analyzed in an analysis of variance by training status, gender, ethnic origin, first language, and section (computer-marked multiple-choice examination vs face-to-face oral and clinical examination).

RESULTS

We found increasing alignment between examiner and candidate characteristics during this period, with a 50% increase in examiners of Asian ethnic origin and a 60% increase in examiners whose first language is not English. The strongest factor in the analysis of variance was training status (F[2, 9818] = 27.67, p < 0.001), with candidates in training significantly outperforming others. Within "core candidates" (first attempt, in training), we found significant main effects for ethnic origin (F[5, 4809] = 2.36, p = 0.04), and first language (F[2, 4809] = 5.29, p = 0.003), but no interaction effects between these factors and section (both F < 1, p > 0.05).

CONCLUSIONS

Training status was the most important factor in candidates' results. Although the analysis showed significant effects of ethnic origin and first language within "core candidates," these differences were statistically indistinguishable between the 2 sections of the examination, suggesting that the differential attainment by these factors cannot be attributed to examiner bias in a face-to-face examination.

Situational judgement tests in medical education and training: Research, theory and practice: AMEE Guide No. 100

Why use SJTs? Traditionally, selection into medical education professions has focused primarily upon academic ability alone. This approach has been questioned more recently, as although academic attainment predicts performance early in training, research shows it has less predictive power for demonstrating competence in postgraduate clinical practice. Such evidence, coupled with an increasing focus on individuals working in healthcare roles displaying the core values of compassionate care, benevolence and respect, illustrates that individuals should be selected on attributes other than academic ability alone. Moreover, there are mounting calls to widen access to medicine, to ensure that selection methods do not unfairly disadvantage individuals from specific groups (e.g. regarding ethnicity or socio-economic status), so that the future workforce adequately represents society as a whole. These drivers necessitate a method of assessment that allows individuals to be selected on important non-academic attributes that are desirable in healthcare professionals, in a fair, reliable and valid way. What are SJTs? Situational judgement tests (SJTs) are tests used to assess individuals' reactions to a number of hypothetical role-relevant scenarios, which reflect situations candidates are likely to encounter in the target role. These scenarios are based on a detailed analysis of the role and should be developed in collaboration with subject matter experts, in order to accurately assess the key attributes that are associated with competent performance. From a theoretical perspective, SJTs are believed to measure prosocial Implicit Trait Policies (ITPs), which are shaped by socialisation processes that teach the utility of expressing certain traits in different settings such as agreeable expressions (e.g. helping others in need), or disagreeable actions (e.g. advancing ones own interest at others, expense). Are SJTs reliable, valid and fair? Several studies, including good quality meta-analytic and longitudinal research, consistently show that SJTs used in many different occupational groups are reliable and valid. Although there is over 40 years of research evidence available on SJTs, it is only within the past 10 years that SJTs have been used for recruitment into medicine. Specifically, evidence consistently shows that SJTs used in medical selection have good reliability, and predict performance across a range of medical professions, including performance in general practice, in early years (foundation training as a junior doctor) and for medical school admissions. In addition, SJTs have been found to have significant added value (incremental validity) over and above other selection methods such as knowledge tests, measures of cognitive ability, personality tests and application forms. Regarding differential attainment, generally SJTs have been found to have lower adverse impact compared to other selection methods, such as cognitive ability tests. SJTs have the benefit of being appropriate both for use in selection where candidates are novices (i.e. have no prior role experience or knowledge such as in medical school admissions) as well as settings where candidates have substantial job knowledge and specific experience (as in postgraduate recruitment for more senior roles). An SJT specification (e.g. scenario content, response instructions and format) may differ depending on the level of job knowledge required. Research consistently shows that SJTs are usually found to be positively received by candidates compared to other selection tests such as cognitive ability and personality tests. Practically, SJTs are difficult to design effectively, and significant expertise is required to build a reliable and valid SJT. Once designed however, SJTs are cost efficient to administer to large numbers of candidates compared to other tests of non-academic attributes (e.g. personal statements, structured interviews), as they are standardised and can be computer-delivered and machine-marked.

Supporting culturally and linguistically diverse students during clinical placement: strategies from both sides of the table

BACKGROUND

Increasing proportions of Culturally and Linguistically Diverse (CALD) students within health professional courses at universities creates challenges in delivering inclusive training and education. Clinical placements are a core component of most health care degrees as they allow for applied learning opportunities. A research gap has been identified in regard to understanding challenges and strategies for CALD students in health professional placements.

METHODS

A key stakeholder approach was used to examine barriers and enablers experienced by CALD students in clinical placement. Semi-structured focus groups with healthcare students (n = 13) and clinical placement supervisors (n = 12) were employed. The focus groups were analysed using open coding and thematic analysis.

RESULTS

Three main barrier areas were identified: placement planning and preparation; teaching, assessment and feedback; and cultural and language issues. Potential solutions included addressing placement planning and preparation barriers, appropriate student placement preparation, pre-placement identification of higher risk CALD students, and diversity training for supervisors. For the barrier of teaching, assessment & feedback, addressing strategies were to: adapt student caseloads, encourage regular casual supervisor-student conversations, develop supportive placement delivery modes and structures, set expectations early, model the constructive feedback process, use visual aids, and tailor the learning environment to individual student needs. The enablers for cultural & language issues were to: build language and practical approaches for communication, raise awareness of the healthcare system (how it interacts with healthcare professions and how patients access it), and initiate mentoring programs.

CONCLUSIONS

The findings suggest that teaching and learning strategies should be student-centred, aiming to promote awareness of difference and its impacts then develop appropriate responses by both student and teacher. Universities and partnering agencies, such as clinical training providers, need to provide an inclusive learning environment for students from multiple cultural backgrounds.

Self-reported extracurricular activity, academic success, and quality of life in UK medical students

OBJECTIVES

To explore the relationship between academic performance, extracurricular activity, and quality of life at medical school in the UK to aid our understanding of students' work-life balance.

METHODS

A cross-sectional study, using an electronic questionnaire distributed to UK final year medical students across 20 medical schools (4478 students). Participants reported the hours of self-regulated learning and extracurricular activities undertaken each year at medical school; along with their academic decile (1 = highest, 10 = lowest). Self-reported quality of life (QoL) was assessed using an established screening tool (7 = highest, 1 = lowest).

RESULTS

Seven hundred responses were obtained, across 20 participating medical schools, response rate 16% (700/4478). Factors associated with higher academic achievement were: graduate entry course students (2 deciles higher, p < 0.0001), more hours academic study during term and revision periods (rho=-0.1, p < 0.01), and involvement in teaching or research. Increased hours of study was associated with lower QoL (rho = -0.13, p < 0.01).

CONCLUSIONS

Study skills may be more important than duration spent studying, for academic achievement and QoL. Graduate-entry students attain higher decile scores despite similar self-reported duration of study.

Predicting performance: relative importance of students' background and past performance

CONTEXT

Despite evidence for the predictive value of both pre-admission characteristics and past performance at medical school, their relative contribution to predicting medical school performance has not been thoroughly investigated.

OBJECTIVES

This study was designed to determine the relative importance of pre-admission characteristics and past performance in medical school in predicting student performance in pre-clinical and clinical training.

METHODS

This longitudinal prospective study followed six cohorts of students admitted to a Dutch, 6-year, undergraduate medical course during 2002-2007 (n = 2357). Four prediction models were developed using multivariate logistic regression analysis. Main outcome measures were 'Year 1 course completion within 1 year' (models 1a, 1b), 'Pre-clinical course completion within 4 years' (model 2) and 'Achievement of at least three of five clerkship grades of ≥ 8.0' (model 3). Pre-admission characteristics (models 1a, 1b, 2, 3) and past performance at medical school (models 1b, 2, 3) were included as predictor variables.

RESULTS

In model 1a - including pre-admission characteristics only - the strongest predictor for Year 1 course completion was pre-university grade point average (GPA). Success factors were 'selected by admission testing' and 'age > 21 years'; risk factors were 'Surinamese/Antillean background', 'foreign pre-university degree', 'doctor parent' and male gender. In model 1b, number of attempts and GPA at 4 months were the strongest predictors for Year 1 course completion, and male gender remained a risk factor. Year 1 GPA was the strongest predictor for pre-clinical course completion, whereas being male or aged 19-21 years were risk factors. Pre-clinical course GPA positively predicted clinical performance, whereas being non-Dutch or a first-generation university student were important risk factors for lower clinical grades. Nagelkerke's R(2) ranged from 0.16 to 0.62.

CONCLUSIONS

This study not only confirms the importance of past performance as a predictor of future performance in pre-clinical training, but also reveals the importance of a student's background as a predictor in clinical training. These findings have important practical implications for selection and support during medical school.

International students' experience of a western medical school: a mixed methods study exploring the early years in the context of cultural and social adjustment compared to students from the host country

BACKGROUND

Few studies have addressed the challenges associated with international students as they adapt to studying medicine in a new host country. Higher level institutions have increasing numbers of international students commencing programmes. This paper explores the experiences of a cohort of students in the early years of medical school in Ireland, where a considerable cohort are from an international background.

METHODS

A mixed exploratory sequential study design was carried out with medical students in the preclinical component of a five year undergraduate programme. Data for the qualitative phase was collected through 29 semi-structured interviews using the peer interview method. Thematic analysis from this phase was incorporated to develop an online questionnaire combined with components of the Student Adaptation to College Questionnaire and Student Integration Questionnaire. First year students were anonymously surveyed online. The Mokken Scaling procedure was used to investigate the students' experiences, both positive and negative.

RESULTS

Three main themes are identified; social adjustment, social alienation and cultural alienation. The response rate for the survey was 49% (467 Respondents). The Mokken Scaling method identified the following scales (i) Positive experience of student life; (ii) Social alienation, which comprised of negative items about feeling lonely, not fitting in, being homesick and (iii) Cultural alienation, which included the items of being uncomfortable around cultural norms of dress and contact between the sexes. With the threshold set to H = 0.4. Subscales of the positive experiences of student life scale are explored further.

CONCLUSIONS

Overall student adjustment to a western third level college was good. Students from regions where cultural distance is greatest reported more difficulties in adjusting. Students from these regions also demonstrate very good adaptation. Some students from the host country and more similar cultural backgrounds were also struggling. Acculturation is more complex than being associated with cultural distance and worthy of further exploration.

Medical school admission test: advantages for students whose parents are medical doctors?

BACKGROUND

Admission candidates especially in medicine do not represent the socio-demographic proportions of the average population: children of parents with an academic background are highly overrepresented, and those with parents who are medical doctors represent quite a large and special group. At Göttingen University Medicine, a new admission procedure was established with the intention to broaden the base of applicants towards including candidates with previous medical training or lower final school grades. With a view to family background, we wished to know whether candidates differ in the test scores in our admission procedure.

METHODS

In February 2014 we asked all admission candidates of Göttingen University Medicine by questionnaire (nine closed, four open questions) about the academic background in their families, specifically, the medical background, school exam grades, and previous medical training as well as about how they prepared for the admission test. We also analysed data from admission scores of this group (semi-structured interview and four multiple mini-interviews). In addition to descriptive statistics, we used a Pearson correlation, means comparisons (t-test, analysis of variance), ANOVA, and a Scheffé test.

RESULTS

In February 2014 nearly half of the applicants (44%) at Göttingen University Medicine had a medical background, most frequently, their parents were physicians. This rate is much higher than reported in the literature. Other socio-demographic baseline data did not differ from the percentages given in the literature. Of all applicants, 20% had previous medical training. The group of applicants with parents who were medical doctors did not show any advantage in either test-scoring (MMI and interview), their individual preparation for the admission test, or in receiving or accepting a place at medical school. Candidates with parents who were medical doctors had scored slightly lower in school exam grades.

CONCLUSION

Our results suggest that there is a self-selection bias as well as a pre-selection for this particular group of applicants. This effect has to be observed during future admission procedures.

Are the General Medical Council's Tests of Competence fair to long standing doctors? A retrospective cohort study

BACKGROUND

The General Medical Council's Fitness to Practise investigations may involve a test of competence for doctors with performance concerns. Concern has been raised about the suitability of the test format for doctors who qualified before the introduction of Single Best Answer and Objective Structured Clinical Examination assessments, both of which form the test of competence. This study explored whether the examination formats used in the tests of competence are fair to long standing doctors who have undergone fitness to practise investigation.

METHODS

A retrospective cohort design was used to determine an association between year of primary medical qualification and doctors' test of competence performance. Performance of 95 general practitioners under investigation was compared with a group of 376 volunteer doctors. We analysed performance on knowledge test, OSCE overall, and three individual OSCE stations using Spearman's correlation and regression models.

RESULTS

Doctors under investigation performed worse on all test outcomes compared to the comparison group. Qualification year correlated positively with performance on all outcomes except for physical examination (e.g. knowledge test r = 0.48, p < 0.001 and OSCE r = 0.37, p < 0.001). Qualification year was associated with test performance in doctors under investigation even when controlling for sex, ethnicity and qualification region. Regression analyses showed that qualification year was associated with knowledge test, OSCE and communication skills performance of doctors under investigation when other variables were controlled for. Among volunteer doctors this was not the case and their performance was more strongly related to where they qualified and their ethnic background. Furthermore, volunteer doctors who qualified before the introduction of Single Best Answer and OSCE assessments, still outperformed their peers under investigation.

CONCLUSIONS

Earlier graduates under fitness to practise investigation performed less well on the test of competence than their more recently qualified peers under investigation. The performance of the comparator group tended to stay consistent irrespective of year qualified. Our results suggest that the test format does not disadvantage early qualified doctors. We discuss findings in relation to the GMC's fitness to practise procedures and suggest alternative explanations for the poorer performance of long standing doctors under investigation.

The effect of English proficiency and ethnicity on academic performance and progress

Non-local ethnicity or nationality and lower English proficiency have been linked with poor performance in health professional education. This study sought to compare the relative contributions of ethnicity and English proficiency, and to do so in a context where students had not been selected via interviews or some other proxy for language proficiency. Ethnicity, citizenship, and demographic data, as well as academic performance and progress were obtained for three successive cohorts (entering in 2007, 2008 and 2009) into a three-year pharmacy programme, following a common first-year. Complete data was available for all 297 students entering via this path. By the end of the programme, controlling for grades at entry, students from some non-local ethnic backgrounds (p < .001) underperformed local students, as did males (p < .001) and those who had been identified as having low English proficiency in year 1 (p < .01). Males (p < .01) and one non-local ethnic group (p < .01) were also more likely to have to repeat a year of study. Ethnicity was a stronger predictor than English proficiency or acculturation, but English proficiency was still independently and additively predictive. This suggests that targeted support strategies for students with lower English language proficiency are still important, but that cultural differences should not be underestimated.

The capability approach for medical education: AMEE Guide No. 97

The capability approach, with its origins in economic and human development work, has a focus on the freedom of persons to make choices about how they wish to lead a valued life. There has been increasing recognition within general education that the capability approach offers a theoretical and practical framework to both implement and evaluate educational interventions that are designed to increase social justice, such as widening participation. There is great potential for the capability approach to also offer medical education a creative way for changing and evaluating curricula, with an emphasis on the teacher facilitating students to achieve their potential by recognising their aspirations and challenging the constraining factors to achieve their aspirations.

Cross-comparison of MRCGP & MRCP(UK) in a database linkage study of 2,284 candidates taking both examinations: assessment of validity and differential performance by ethnicity

BACKGROUND

MRCGP and MRCP(UK) are the main entry qualifications for UK doctors entering general [family] practice or hospital [internal] medicine. The performance of MRCP(UK) candidates who subsequently take MRCGP allows validation of each assessment. In the UK, underperformance of ethnic minority doctors taking MRCGP has had a high political profile, with a Judicial Review in the High Court in April 2014 for alleged racial discrimination. Although the legal challenge was dismissed, substantial performance differences between white and BME (Black and Minority Ethnic) doctors undoubtedly exist. Understanding ethnic differences can be helped by comparing the performance of doctors who take both MRCGP and MRCP(UK).

METHODS

We identified 2,284 candidates who had taken one or more parts of both assessments, MRCP(UK) typically being taken 3.7 years before MRCGP. We analyzed performance on knowledge-based MCQs (MRCP(UK) Parts 1 and 2 and MRCGP Applied Knowledge Test (AKT)) and clinical examinations (MRCGP Clinical Skills Assessment (CSA) and MRCP(UK) Practical Assessment of Clinical Skills (PACES)).

RESULTS

Correlations between MRCGP and MRCP(UK) were high, disattenuated correlations for MRCGP AKT with MRCP(UK) Parts 1 and 2 being 0.748 and 0.698, and for CSA and PACES being 0.636. BME candidates performed less well on all five assessments (P < .001). Correlations disaggregated by ethnicity were complex, MRCGP AKT showing similar correlations with Part1/Part2/PACES in White and BME candidates, but CSA showing stronger correlations with Part1/Part2/PACES in BME candidates than in White candidates. CSA changed its scoring method during the study; multiple regression showed the newer CSA was better predicted by PACES than the previous CSA.

CONCLUSIONS

High correlations between MRCGP and MRCP(UK) support the validity of each, suggesting they assess knowledge cognate to both assessments. Detailed analyses by candidate ethnicity show that although White candidates out-perform BME candidates, the differences are largely mirrored across the two examinations. Whilst the reason for the differential performance is unclear, the similarity of the effects in independent knowledge and clinical examinations suggests the differences are unlikely to result from specific features of either assessment and most likely represent true differences in ability.

Bridging the gap: the roles of social capital and ethnicity in medical student achievement

OBJECTIVES

Within medical education, there is a discrepancy between the achievement level of White students and that of their ethnic minority peers. The processes underlying this disparity have not been adequately investigated or explained. This study utilises social network analysis to investigate the impact of relationships on medical student achievement by ethnicity, specifically by examining homophily (the tendency to interact with others in the same group) by ethnicity, age and role.

METHODS

Data from a cross-sectional social network study conducted in one UK medical school are presented and are analysed alongside examination records obtained from the medical school. Participants were sampled across the four hospital placement sites; a total of 158 medical students in their clinical phase (Years 3 and 4) completed the survey. The research was designed and analysed using social capital theory.

RESULTS

Although significant patterns of ethnic and religious homophily emerged, no link was found between these factors and achievement. Interacting with problem-based learning (PBL) group peers in study-related activities, and having seniors in a wider academic support network were directly linked to better achievement. Students in higher academic quartiles were more likely to be named by members of their PBL group in study activities and to name at least one tutor or clinician in their network. Students from lower-achieving groups were least likely to have the social capital enabling, and resulting from, interactions with members of more expert social groups.

CONCLUSIONS

Lower levels of the social capital that mediates interaction with peers, tutors and clinicians may be the cause of underperformance by ethnic minority students. Because of ethnic homophily, minority students may be cut off from potential and actual resources that facilitate learning and achievement.