#KeyLIMEPodcast 239: Equity, Diversity and Inclusiveness. Too little. Too long. [Recorded LIVE at ICRE 2019!]

Reference

Simone et. al., What are the features of targeted or systemwide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50 2018 Medical Teacher, 40:8, 762-780,

Reviewer

Jon Sherbino (@sherbino)

Background

The social contract with society that grants the professional autonomy enjoyed by medicine, presumes that physicians and physician institutions will act in the best interests of society.  This presumption has been strained by a lack of representation by women, people of colour, the LGBT community, people with disabilities, people from low socioeconomic background among many others.  Under representation of the diversity of communities that make up society leads to healthcare policies, healthcare access and healthcare representation that is discriminatory and priviledged.

More recently, health professions education training programs have been called to account, to ensure that the representation of trainees in their professional programs are representative of society. Interventions in admission processes are challenging because they must address longstanding issues of inappropriate use of power.

So, lets dive into a review of initiatives that try to tackle admissions processes that are unfair, biased and discriminatory. The authors address interventions that “promote recruitment for application by a more diverse population… [and]… support success in admission by a more diverse population.”  They recognize that other types of interventions can “support retention and completion of programs by a more diverse population, [or]… recruit and retain health professionals to work with more diverse populations,” but this is not their focus.

Purpose

“…we sought to determine which interventions aimed at increasing under-represented populations are associated with meeting the desired outcomes of increasing the representation of these populations within the health professions student body.”

Key Points on the Methods

The study is informed by Bandura’s self-efficacy learning theory, which emphasizes components for learning, include: experience, modeling, social persuasion and physiology.  If health professions training is homogeneous, than the experience, modelling and social persuasion experienced in school will preserve the established power structures in training.

The focus was on the initial entry point into HP training; advanced training (e.g. PGME, fellowships) was excluded.

All of the typical databases were searched (updated 2017), and then some! (n=21). Inclusion criteria were broad, including any health profession, any relevant intervention, any quantitative or qualitative outcome and any study type.  Exclusion criteria were minimal. Notable exclusions were studies that only had learner satisfaction outcome data or post-intervention studies without an established base rate. Authors were contacted for unpublished data.  Conference proceedings were hand searched.  A google scholar search of the gray literature was performed.

Two reviewers independently screened studies in typical sequentially complex stages. Data extraction quality was monitored via a 20% redundant recheck.

Study quality was evaluated by two independent reviewers using the Cochrane Effective Practice and Organization of Care – EPOC- (for quantitative outcomes) and the Critical Appraisal Skills Program Qualitative Checklist -CASP- (for qualitative outcomes).

Synthesis of the studies was conducted using a quasi-thematic analysis performed in an iterative fashion by the study team.

Key Outcomes

7242 studies were identified; 86 were included. 38 studies had an independent comparator.  These studies were described in greater detail.

Publication dates ranged from 1972-2016 with 70% published since 2000. 80% were published in the USA. The majority of the studies were conducted in medicine. 75% were single centre studies. Half of the studies used before-after design. Two-thirds of the studies defined the under represented minority (URM) with the vast majority defining URM based on race/ethnic background.

34% of studies intervened in the admissions process. 19% were enrichment programs, 15% outreach programs, and 3% curriculum interventions. The remainder were mixed interventions.

Admissions

• Differential weighting (e.g. points systems) increased URM admission (11 studies), but findings are hampered by low quality.
• Holistic admission criteria (i.e. increased emphasis on nonacademic or personal elements) increased URM representation(5 studies), although the evidence was not strong and 1 study found no effect.
• Standardized tests (2 studies) (e.g. situational judgment tests) showed a mixed effect.
• Providing advice and assistance through the application process improved acceptance rates for URM in 1 study.
• Adjusting thresholds for grade point average or standardized tests (4 studies) (e.g. MCAT) may have some effect, the results are limited.
• Blinding of names and ethnicity was both time consuming and ineffective in increasing URM admission in 1 study.
• Educating admissions committee members improved URM admissions in 1 study.

Enrichment programs

• Four of five studies showed increase URM application or admission rate via summer enrichment programs, but results are limited by quality.
• One year post-baccalaureate programs were recommended by 3 studies to increase diversity but the outcomes limit generalizability.

Outreach programs

• Two studies increased URM interest in HPE via observerships and interactions with HPE learners and faculty.
• One study showed no impact with targeted recruitment.

Curriculum

• Two studies examined an MD-MSc program designed to train students to work in under-served communities to increase admission of URM.

Mixed Interventions

• 14 studies (10 positive, 2 negative 2 neutral) examined a mixed intervention to increase URM representation in California dental schools using combinations of revised admissions processes, summer enrichment programs, standardized test preparation, post-baccalaureate programs, pre-matriculation programs, targeted recruitment, mentoring or academic advising, outreach programs involving middle school, high school and/or undergraduate students, career fairs, and/or financial aid.

‘SUMMARY STATEMENTS’

• An intervention likely had a positive effect on URM representation when compared to no intervention. However, the quality of the data and generalizability of the findings are not robust. Rather than a “single-best” intervention a ‘pipeline model’ may be a better approach.
• Increasing the size of the applicant pool, rather than only increasing the competitiveness of URM applicants, should be a priority.
• The most efficient/effective interventions target the admissions process.

Key Conclusions

The authors conclude…

“In all areas, the majority of studies reported positive results, with the greatest representation in the areas of admissions and enrichment interventions. This suggests that any intervention type is likely to increase intended diversity dimensions over status quo. .. However, interpretation of these findings must consider several caveats. First, several of the included studies reported that current interventions increased the competitiveness of the URM applicant pool but did not necessarily expand it… Second, the included studies in our review were limited in that they were most often…focused on ethnicity and race.”

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