Inclusivity in transitioning to medical school.

Abstract

The transition from school to higher education (HE) can involve stark changes for learners, such as the physical move away from home.1 Research suggests familiarity with the HE context comes from family background and prior engagement with ‘academic’ settings,1 which correlates with socio-economic status.2 In medicine, connections with health professionals are advantageous.3 A successful transition into university means feeling that you belong1 as well as working out new ways of learning. In the United Kingdom, as widening participation (WP) initiatives expand access to more diverse student cohorts,4 the numbers of students for whom the transition may be more challenging increases. The current focus of WP is enabling success while at university and beyond.4 Barriers to learning range from emotional disengagement from not fitting in to inaccessible learning environments and educational activities. Barriers to learning range from emotional disengagement from not fitting in to inaccessible learning environments and educational activities. Around 17% of all UK university students are diagnosed with a disability, the most common of which are specific learning difficulties (SpLDs),5 including dyslexia and Autism Spectrum Disorder. Neurodivergent students can find the transition into HE overwhelming due to perceptions of difference and disadvantage compared to neurotypical students.6 As HE systems and practices have typically been designed for neurotypical students,6 carefully considered inclusive pedagogies and reasonable adjustments are needed to allow these students to reach their full potential. The following toolbox has been cocreated by medical students and educators through a process involving reviewing literature, discussions with stakeholders and personal reflections. Our stakeholders included academics, educators, programme leads, clinicians and students. We considered both WP status and disability in this toolbox as an intersectional analysis may serve to highlight specific issues, such as the potential for financial burden to prohibit diagnosis and subsequently access to support. A lack of support and integration at the start of medical school can negatively impact students with SpLDs.6 We acknowledge that both groups of students can experience difference as a challenge rather than feeling that differences are welcomed and valued.7 While our experiences are from a single UK medical school, the following recommendations could generally apply to supporting medical students' experiences of transition, in both on-campus and clinical placement contexts. The toolbox was shared with staff in the Faculty of Medicine and Health, offering tips for making the transition to HE more inclusive. A further resource for students was created using Microsoft Sway, offering tips to incoming Medicine Foundation Year and Year 1 MBChB students upon enrolment in 2022/23. With medical student populations becoming increasingly diverse,8 it is important to consider the variety of experiences that students bring. The General Medical Council (GMC)7 recognises that a diverse workforce can better serve diverse patients. We have similarly observed several advantages that students from varied backgrounds bring to medicine. For example, experience of disability, such as SpLDs, may allow greater empathy with patients. Similarly, those from low-income backgrounds may have a better understanding of the experiences of health for patients from similar backgrounds. An example would be considering how prescription costs could impact patients in financial difficulties and signposting to financial support. The General Medical Council (GMC)7 recognises that a diverse workforce can better serve diverse patients. Experiencing disadvantages can provide medical students the opportunity to develop personal skills. Students from low-income backgrounds may work part-time to help pay for living costs which can bring benefits such as improved time management. Educators and clinical tutors can support these students by giving sufficient time for pre-class self-directed learning or by releasing timetable information in advance to allow planning of other responsibilities around learning commitments. This advanced information can also allow students with disabilities to plan their study and placement time, orient themselves to the upcoming tasks and make any necessary arrangements. Difference can also be a source of isolation. Many students on our Medicine Foundation Year related to feelings of imposter syndrome. While these feelings are often experienced by traditional-entry medical students,9 the lower grade entry requirements for the Foundation Year are likely to intensify these feelings. Our educator stakeholders identified a greater need to reassure students on the Foundation Year that they do belong, and their experiences can be advantageous. In our context, medical students intercalating (taking a year out to study an additional degree) in Medical Education have been involved in teaching on the Medicine Foundation Year. We found that this had positive impacts on the Foundation Year students' experiences of transition. Foundation students expressed a strong rapport between themselves and their near-peer educators, crucially alleviating anxieties and feelings of imposter syndrome. This may be explained by the theory of social and cognitive congruence, where near-peer mentors and educators with shared backgrounds or experiences of disability can create a stronger rapport between students and their teachers.10 Students often feel more comfortable seeking support from educators who have shared experiences and understanding, potentially originating from prior training and teaching experience. Conversely, a lack of training or awareness among staff can hinder student success.11 One of our clinician-educator stakeholders had recently completed a postgraduate qualification in special educational needs and found this developed their understanding of how to support students with SpLDs to overcome educational challenges. A lack of training or awareness among staff can hinder student success. Universities and placement providers have a responsibility to ensure that support is accessible. Contact details for support services and examples of support available should be clearly displayed. Directly contacting students with known disabilities to outline the support available also ensures that they know where to go for help. The variety of contexts in which medical students learn means the range of support options and inclusive teaching strategies will be more variable than standard adjustments recommended in HE. For example, a student with dyspraxia may not experience barriers to learning until they attempt their first cannulation. Educators also cannot assume that a condition implies a particular set of barriers for the learner; conditions can present in a variety of ways and alongside other conditions. Understanding and addressing this variability in medical education contexts will require collaboration between students and educators. Unfortunately, students often have preconceived ideas that disclosing their struggles may make them appear unable to cope with medical school. It is therefore important to address stigma as part of a review of accessibility. Student engagement in such reviews can be promoted through open forums where students feel comfortable raising concerns. Private conversations at the end of a seminar or lecture can enable more in-depth explorations of barriers and opportunities for promoting inclusion of all learners. At our medical school, students have found anonymous online question boards, such as Padlet, a great way to ask what they perceive to be ‘silly’ questions without fear of embarrassment. The first few weeks of term are a critical period in which tutors should encourage and facilitate social networking to support transition to HE. After this, building relationships can be more difficult as most students will have already established friendships.1 The dominant identity in HE is typically middle class, so students from working-class backgrounds often struggle relating to their peers.2 Those from upper- and middle-class backgrounds are more likely to have already gained sufficient social and informational capital to understand the ‘rules of the game’ within HE (Bourdieu12 p. 78). Heterogeneous grouping of students can enable those from working-class backgrounds to gain access to aspects of the hidden curriculum they were previously unaware of.13 As educators and clinical teachers, we can facilitate this with paired or group work, allowing development of peer connections and support networks. From personal experience, we have found that consistent tutor-groups and placement groups throughout the year encourage longer term relationships to develop and stronger rapports with tutors. Having different student groups for different modules can mitigate the issue of students not gelling with their group and offer more opportunities to develop social relationships. Those from upper- and middle-class backgrounds are more likely to have already gained sufficient social and informational capital. One of our educator stakeholders schedules ‘social’ time into lesson plans, especially at the start of the year, to encourage social networking between students. Planning more time for discussion tasks allows students to network and build social relationships. While this may be seen as including less content in the lesson, it is worth considering the long-term benefits of socialisation in the transition to HE in developing sense of belonging.2 Early conversations with students can help to establish specific educational needs and support. Students with long-standing formal diagnoses of SpLDs are likely to have developed their own unique ways of learning. Educators can best support students in how they learn by communicating with students. Offering regular drop-in sessions for students and educators to check-in may reduce the known tendency for students to only access support when struggling.6 Early conversations with students can help to establish specific educational needs and support. At our institution, a set of ‘baseline standards’ for inclusivity were created in 2018 to ensure teaching and learning materials and practices are inclusive for all.5 Additionally, the baseline standards recommend releasing teaching materials in advance and including a range of methods of assessment. School academic leads for inclusive practice were brought in to facilitate the implementation of these standards. While progress has been made towards meeting these standards, a 2022 review5 found that further staff training in inclusivity and institutional strategies for digital accessibility are needed. Understanding students' backgrounds and pertinent issues will allow educators to be more sensitive and respectful within group discussions and meetings. Respect can be expressed through recognition of students' strengths due to unique capabilities, which build resilience, empathy and insights that may not be widely known. Sensitivity can be shown by being mindful that students from WP backgrounds may have had difficult experiences that they may not feel comfortable sharing. An awareness of inclusive language can further support students' sense of belonging by avoiding generalisations about students' backgrounds. For example, instead of asking ‘What A-levels did you do?’, you could ask ‘What did you do before university?’. This subtle difference could mean that students who entered via a non-traditional route are not made to feel further excluded. Asking ‘Is there anything about you that could be helpful to know so I can best support you?’ can be a better way of asking students to disclose their SpLDs or other factors that could impact learning. Labels like ‘dyslexic’ are not only associated with stigma but can also generalise in ways that disregard differences in types of dyslexia. The open question also means those with dyslexia can share this in their response. Instead of asking ‘What A-levels did you do?’, you could ask ‘What did you do before university?’ Building relationships with students may also counteract stereotype threat.14 As minority groups, WP students and those with SpLDs may benefit from events where underrepresented staff share their experiences (e.g., through a panel or network). In the longer term, universities should recruit staff from more diverse backgrounds to better promote positive role-modelling. Many thanks to Dr Alison Ledger for providing feedback on our draft manuscript. The authors also give thanks to the various stakeholders who kindly shared their thoughts and experiences with us. The authors have no conflict of interest to disclose. The authors have no ethical statement to declare.