Widening access to medicine: A realist review.

Introduction: Despite policy drivers and "on-the-ground" activity to encourage applicants from under-represented minority groups (URMs) into medicine, their representation remains limited because of the challenge of overcoming complex societal and systemic barriers. This realist review sought to review the existing literature to identify underlying CIMOs with respect to widening access (WA) to medical school.

Method: We conducted a realist literature review informed by Pawson's five iterative strategies and consistent with RAMESES standards. We searched eight electronic databases (MEDLINE, EMBASE, CINAHL Plus, PsycInfo, JBI EBP, ERIC, Scopus, Proquest Public Health) to identify studies published from 1990 to April 2023 on WA pathways into medical school. We used a realist logic of analysis to examine how the mechanisms of action (M) identified for each WA intervention (I) triggered outcomes (O) related to widening access, and thus increasing cohort diversity, in different contexts (C).

Results: Thirty-two of 6300 studies identified and screened met the inclusion criteria. Most papers were from Global North countries (31/32). They reported five types of WA interventions: Minimising Bias; Modifying selection criteria; Community Collaboration; Preparing applicants for selection and studying medicine; Combining College with Medical School. Mechanisms were categorised as addressing institutional, situational, or dispositional barriers to studying medicine. Interventions were classified as addressing WA at a system-level or individual-level. There were four outcomes of interest: established widened selection pathways; an increased number of pathway applications for medical school; a change in offers for medical school, and increased cohort diversity.

Conclusions: This review highlights that issues with access to medical education are still being seen as individual not systemic, with most reported WA interventions focussing predominantly on addressing situational and dispositional 'barriers' to medical education. The dominant implicit positioning of the applicant as the only aspect in the WA process in need of change reinforces the status quo.