Seeking inclusion in an exclusive process: discourses of medical school student selection.

Abstract

Calls to increase medical class representativeness to better reflect the diversity of society represent a growing international trend. There is an inherent tension between these calls and competitive student selection processes driven by academic achievement. How is this tension manifested? Our three-phase interdisciplinary research programme focused on the discourses of excellence, equity and diversity in the medical school selection process, as conveyed by key stakeholders: (i) institutions and regulatory bodies (the websites of 17 medical schools and 15 policy documents from national regulatory bodies); (ii) admissions committee members (ACMs) (according to semi-structured interviews [n = 9]), and (iii) successful applicants (according to semi-structured interviews [n = 14]). The work is theoretically situated within the works of Foucault, Bourdieu and Bakhtin. The conceptual framework is supplemented by critical hermeneutics and the performance theories of Goffman. Academic excellence discourses consistently predominate over discourses calling for greater representativeness in medical classes. Policy addressing demographic representativeness in medicine may unwittingly contribute to the reproduction of historical patterns of exclusion of under-represented groups. In ACM selection practices, another discursive tension is exposed as the inherent privilege in the process is marked, challenging the ideal of medicine as a meritocracy. Applicants' representations of self in the 'performance' of interviewing demonstrate implicit recognition of the power inherent in the act of selection and are manifested in the use of explicit strategies to 'fit in'. How can this critical discourse analysis inform improved inclusiveness in student selection? Policymakers addressing diversity and equity issues in medical school admissions should explicitly recognise the power dynamics at play between the profession and marginalised groups. For greater inclusion and to avoid one authoritative definition of excellence, we suggest a transformative model of faculty development aimed at promoting multiple kinds of excellence. Through this multi-pronged approach, we call for the profession to courageously confront the cherished notion of the medical meritocracy in order to avoid unwanted aspects of elitism.