Diversity in the pathway from medical student to specialist in the Netherlands: a retrospective cohort study.

Background: Medical specialist workforces are not representative of the society they serve, partially due to loss of diversity in the path from student to specialist. We investigated which demographic characteristics of bachelor students of medicine (BSM) are associated with becoming a physician and (particular type of) medical specialist; and whether this suggests 'cloning' (reproduction of sameness) of the existing workforce. Methods: We used a retrospective cohort design, based on Statistics Netherlands data of all first-year BSM in 2002-2004 in The Netherlands (N = 4503). We used logistic regression to analyze the impact of sex, migration background, urbanity of residence, parental income and assets categories, and having healthcare professional parents, on being registered as physician or medical specialist in 2021. We compared our results to the national pool of physicians (N = 76,845) and medical specialists (N = 49,956) to identify cloning patterns based on Essed's cultural cloning theory. Findings: Female students had higher odds of becoming a physician (OR 1.87 [1.53-2.28], p < 0.001). Physicians with a migration background other than Turkish, Moroccan, Surinamese, Dutch Caribbean or Indonesian (TMSDI) had lower odds of becoming a specialist (OR 0.55 [0.43-0.71], p < 0.001). This was not significant for TMSDI physicians (OR 0.74 [0.54-1.03], p = 0.073). We found a cloning pattern with regard to sex and migration background. Nationwide, physicians with a Turkish or Moroccan migration background, and female physicians with other migration backgrounds, are least likely to be a medical specialist. Interpretation: In light of equity in healthcare systems, we recommend that every recruitment body increases the representativeness of their particular specialist workforce. Funding: ODISSEI.

Inequality of opportunity in selection procedures limits diversity in higher education: An intersectional study of Dutch selective higher education programs.

Selection for higher education (HE) programs may hinder equal opportunities for applicants and thereby reduce student diversity and representativeness. However, variables which could play a role in inequality of opportunity are often studied separately from each other. Therefore, this retrospective cohort study conducts an innovative intersectional analysis of the inequality of opportunity in admissions to selective HE programs. Using a combination of multivariable logistic regression analyses and descriptive statistics, we aimed to investigate 1) the representativeness of student populations of selective HE programs, as compared to both the applicant pool and the demographics of the age cohort; 2) the demographic background variables which are associated with an applicant's odds of admission; and 3) the intersectional acceptance rates of applicants with all, some or none of the background characteristics positively associated with odds of admission. The study focused on all selective HE programs (n = 96) in The Netherlands in 2019 and 2020, using Studielink applicant data (N = 85,839) and Statistics Netherlands microdata of ten background characteristics. The results show that student diversity in selective HE programs is limited, partly due to the widespread inequality of opportunity in the selection procedures, and partly due to self-selection. Out of all ten variables, migration background was most often (negatively) associated with the odds of receiving an offer of admission. The intersectional analyses provide detailed insight into how (dis)advantage has different effects for different groups. We therefore recommend the implementation of equitable admissions procedures which take intersectionality into account.

The reporting of ethical review and ethical considerations in articles published in medical education journals: A literature review.

BACKGROUND: Health professions education research (HPE-R) must be ethically sound. Ethical review decisions and other ethical considerations should be clearly reported in journal articles to allow readers to assess the ethical soundness of the research. We explored and evaluated how ethical review decisions and ethical considerations for HPE-R are reported in health professions education (HPE) journal articles. METHODS: We identified a 1-year sample, for 2020, of eight HPE journals. We systematically assessed the reporting of ethical review and key ethical considerations in the articles in the sample. RESULTS: The search yielded 2004 articles, of which 955 articles (47.7%) were eligible and were thus assessed. Most (83.4%) of the assessed articles mentioned a review by an ethical review board (ERB). In the category 'research articles', 92% articles reported the outcome of the ethical review. In the category 'other articles' (e.g. educational case reports), reporting of ethical processes was less common (32%). Overall, the reporting of key ethical considerations was limited, although these considerations were more reported in 'research articles' compared with 'other articles'. CONCLUSIONS: ERB assessments and HPE-R approval was reported in most research articles. This finding is an improvement compared with previous evaluations of ethical research practice in HPE-R. All studies, particularly those that are exempted or not fully reviewed, should describe their key ethical considerations clearly to enable the HPE community to assess the ethical soundness. Our review revealed that the reporting of ethical considerations was limited and deserves attention from the research community.

Applicant perceptions of selection methods for health professions education: Rationales and subgroup differences.

CONTEXT: Applicant perceptions of selection methods can affect motivation, performance and withdrawal and may therefore be of relevance in the context of widening access. However, it is unknown how applicant subgroups perceive different selection methods. OBJECTIVES: Using organisational justice theory, the present multi-site study examined applicant perceptions of various selection methods, rationales behind perceptions and subgroup differences. METHODS: Applicants to five Dutch undergraduate health professions programmes (N = 704) completed an online survey including demographics and a questionnaire on applicant perceptions applied to 11 commonly used selection methods. Applicants rated general favourability and justice dimensions (7-point Likert scale) and could add comments for each method. RESULTS: Descriptive statistics revealed a preference for selection methods on which applicants feel more 'in control': General favourability ratings were highest for curriculum-sampling tests (mean [M] = 5.32) and skills tests (M = 5.13), while weighted lottery (M = 3.05) and unweighted lottery (M = 2.97) were perceived least favourable. Additionally, applicants preferred to distinguish themselves on methods that assess attributes beyond cognitive abilities. Qualitative content analysis of comments revealed several conflicting preferences, including a desire for multiple selection methods versus concerns of experiencing too much stress. Results from a linear mixed model of general favourability indicated some small subgroup differences in perceptions (based on gender, migration background, prior education and parental education), but practical meaning of these differences was negligible. Nevertheless, concerns were expressed that certain selection methods can hinder equitable admission due to inequal access to resources. CONCLUSIONS: Our findings illustrate that applicants desire to demonstrate a variety of attributes on a combination of selection tools, but also observe that this can result in multiple drawbacks. The present study can help programmes in deciding which selection methods to include, which more negatively perceived methods should be better justified to applicants, and how to adapt methods to meet applicants' needs.

Influence of social networks in healthcare on preparation for selection procedures of health professions education: a Dutch interview study.

OBJECTIVES: Health professions education (HPE) students are often not representative of the populations they will serve. The underrepresentation of non-traditional students is problematic because diversity is essential for promoting excellence in health education and care. This study aimed to understand the perceptions of traditional and non-traditional students regarding facilitators and barriers in preparing for HPE selection procedures, and to determine the role of social networks in their decision-making and preparations to apply. METHODS: A qualitative study was conducted with 26 Dutch youth who were interested in university-level HPE programmes. Semistructured interviews and sociograms were analysed using thematic analysis, adopting a constructivist approach. RESULTS: Twenty-six high school students participated, with traditional and non-traditional backgrounds, with and without social networks in healthcare and higher education. Two themes were constructed. First, four high-impact facilitators helped to overcome barriers to apply and in preparation for selection: access to a social network connection working or studying in healthcare, to correct information, to healthcare experience and to a social network connection in higher education. Lack of information was the main barrier while access to social network connections in healthcare was the main facilitator to overcome this barrier. However, this access was unevenly distributed. Second, access alone is not enough: the need for agency to make use of available facilitators is also essential. CONCLUSIONS: The themes are discussed using intersectionality. Traditional students with access to facilitators develop their self-efficacy and agency within social structures that privilege them, whereas non-traditional students must develop those skills without such structures. Our findings provide recommendations for the ways in which universities can remove barriers that cause unequal opportunities to prepare for the selection of HPE programmes. Along with equitable admissions, these recommendations can help to achieve a more representative student population and subsequently a better quality of health education and care.

Selection for health professions education leads to increased inequality of opportunity and decreased student diversity in The Netherlands, but lottery is no solution: A retrospective multi-cohort study.

BACKGROUND: Concerns exist about the role of selection in the lack of diversity in health professions education (HPE). In The Netherlands, the gradual transition from weighted lottery to selection allowed for investigating the variables associated with HPE admission, and whether the representativeness of HPE students has changed. METHOD: We designed a retrospective multi-cohort study using Statistics Netherlands microdata of all 16-year-olds on 1 October 2008, 2012, and 2015 (age cohorts, N > 600,000) and investigated whether they were eligible students for HPE programs (n > 62,000), had applied (n > 14,000), and were HPE students at age 19 (n > 7500). We used multivariable logistic regression to investigate which background variables were associated with becoming an HPE student. RESULTS: HPE students with ≥1 healthcare professional (HP) parent, ≥1 top-10% income/wealth parent, and women are overrepresented compared to all age cohorts. During hybrid lottery/selection (cohort-2008), applicants with ≥1 top-10% wealth parent and women had higher odds of admission. During 100% selection (cohort-2015) this remained the case. Additionally, applicants with ≥1 HP parent had higher odds, those with a migration background had lower odds. CONCLUSIONS: Odds of admission are increasingly influenced by applicants' backgrounds. Targeted recruitment and equitable admissions procedures are required to increase matriculation of underrepresented students.

What stressors and energizers do PhD students in medicine identify for their work: A qualitative inquiry.

INTRODUCTION: Rising mental health issues is a global problem among PhD students. This study aimed to identify stressors and energizers in PhD work. METHODS: PhD students at a university medical center were asked to describe the top three stressors and energizers in their PhD work through a survey. The narrative answers were subjected to content analysis. RESULTS: Three hundred and eighty-six PhD students participated. We identified five overarching themes: Research is challenging, Resources can be limited, Recognizing the value of work, Experience of autonomy, and Relationships are key to success. We found positive (energizers) as well as negative (stressors) comments for each theme. DISCUSSION: Supportive supervision with open communication has been identified in the literature as the most important contributor to PhD student well-being, while work-life imbalance has been identified as the most important reason for psychological distress. With our study, we add energizers and stressors that fit into a theoretical framework (Self-determination theory). This helps to understand the problem better and provide specific recommendations. CONCLUSIONS: Optimal challenges, resources and supervision, autonomy and good relationships at work are perceived as energizers. Challenges in research beyond capability, limitations in resources, not being valued, autonomy restriction and poor relationships at work are perceived as stressors in PhD work.

Exploring Factors Associated With the Motivation of Clinical Pharmacists: A Focus on the South African Context.

Introduction: Pharmacy practice in many middle to low-income countries has slowly transitioned from being product-focused to a more patient-focused clinical practice. Lack of motivation is one of the factors contributing to the scarcity of pharmacists in the wards. As little is known about motivation in clinical pharmacists, this study aimed to obtain insight into the quantity and quality of their work motivation and factors associated with it. Methods: Self-determination Theory, used as the framework, describes autonomous motivation as being generated from within or through personal endorsement and controlled motivation as originating from external factors. An online questionnaire including the Academic Motivation Scale to measure autonomous motivation, controlled motivation and amotivation, was sent to clinical pharmacy graduates from 2000 to 2020 across South Africa, followed by interviews to explain some results. Independent t-test was used to analyze differences in motivation of clinical pharmacists to perform clinical services based on personal and environmental factors. Interview data were transcribed and analyzed to explain significant quantitative findings. Results: Higher amotivation was found in graduates who are currently not practicing in dedicated clinical pharmacist positions, as well as in graduates who do not receive additional financial benefits for clinical services. We found no significant differences in the work motivation of clinical pharmacists based on their gender, age, current practice setting, work experience and additional training received. The interviews revealed that relatedness and autonomy are the most important factors for clinical pharmacists' work motivation. Discussion: Overall participants had a high mean autonomous motivation, a high mean controlled motivation and low mean amotivation. In line with Self-determination Theory literature, considering the basic psychological needs for relatedness and autonomy could assist with designing interventions, like creating a supportive work environment, to optimize motivation. This could improve professional wellbeing, service implementation and prevent possible adverse events. Future research is necessary to understand barriers and facilitators of clinical pharmacists' work motivation.

"As an ethnic minority, you just have to work twice as hard." Experiences and motivation of ethnic minority students in medical education.

INTRODUCTION: Adequate representation of ethnic minority groups in the medical workforce is crucial for ensuring equitable healthcare to diverse patient groups. This requires recruiting ethnic minority medical students and taking measures that enable them to complete their medical studies successfully. Grounded in self-determination theory and intersectionality, this paper explores the experiences of ethnic minority medical students across intersections with gender and other categories of difference and how these relate to students' motivation. METHODS: An explorative, qualitative study was designed. Six focus groups were conducted with 26 ethnic minority students between December 2016 and May 2017. Thematic analysis was performed to identify, analyse and report themes within the data. RESULTS: The findings were categorized into three main themes: the role of autonomy in the formation of motivation, including students' own study choice and the role of their family; interactions/'othering' in the learning environment, including feelings of not belonging; and intersection of ethnic minority background and gender with being 'the other', based on ethnicity. DISCUSSION: Ethnic minority students generally do not have a prior medical network and need role models to whom they can relate. Ensuring or even appointing more ethnic minority role models throughout the medical educational continuum-for example, specialists from ethnic minorities in teaching and/or mentoring roles in the education-and making them more visible to students is recommended. Moreover, a culture needs to be created in the educational environment in which students and staff can discuss their ethnicity-related differences.

Validation of the professional identity questionnaire among medical students.

BACKGROUND: Professionalism represents a cornerstone of the medical profession, prompting medical educators to actively develop instruments to measure professional identity formation among medical students. A quantitative approach to this problem has been lacking. Hence in this study, we investigate the validity and reliability of using Brown et al.'s [1986] Professional Identity Questionnaire (PIQ) to measure professional identity among medical students. METHODS: We used the American Psychological Association's account of validity and reliability to examine the PIQ in terms of its internal structure, its relation to a validated motivation scale, its content, and its internal consistency. To this end, we performed two factor analyses, a Pearson's correlation test, an expert evaluation and measured Cronbach's alpha, respectively.. RESULTS: Factor analysis revealed two latent factors underlying the items of the PIQ. We found a negative to positive spectrum of Pearson's correlations corresponding to increasingly internal qualities of motivation. Experts unanimously rated four out of ten of the PIQ's items as relevant, reliability analysis yielded a Cronbach's alpha value of 0.82. CONCLUSION: Despite poor ratings by experts in the field, these results illustrate the PIQ as a valid and reliable quantitative measure of medical students' professional identity; its two factors reflecting the measure of attached and detached attitudes towards the medical profession. Educators may use the instrument as a tool for monitoring PIF among their students, as well as for designing and evaluating their medical curriculum. Future research might build on the current findings by investigating other dimensions of the PIQ's validity, including response process validity, predictive validity and consequential validity.

"What kind of support do I need to be successful as an ethnic minority medical student?" A qualitative study.

BACKGROUND: To be in alignment with the increasing diversity in the patient population, ethnic minorities should have appropriate representation in health care professions. Medical students from ethnic minorities therefore need to be successful in their medical studies. The current literature highlights that they underperform in comparison with the ethnic majority. The aim of the present study is to gain insight into what medical students from ethnic minorities experience during their education and what they need to become or stay motivated and to perform to their full potential. METHODS: Medical students from ethnic minorities from year 1 to 6, enrolled at Amsterdam UMC, Faculty of Medicine, Vrije Universiteit, the Netherlands, were invited via email to participate in this study. Semi-structured interviews were conducted, using an interview guide, from August-October 2018. A constructivist paradigm was adopted. RESULTS: Eighteen medical students from ethnic minorities (three from year 1, three from year 2, one from 3, four from year 4, two from year 5, and three from year 6) participated in this study. Students' negative experiences could be categorized as follows: (1) the effect of discrimination (2) lack of representation of ethnic minority role models, (3) lack of a sense of belonging, (4) lack of a medical network, (5) differences and difficulties in cultural communication and language, and (6) examiner bias in clinical assessments. Examples of support tips relating to these experiences are: increasing awareness about diversity and other religions, providing support groups, having visible ethnic minority role models, and facilitating support in networking. CONCLUSIONS: Findings of this study suggest that medical students from ethnic minorities have negative experiences that influence their education. Supporting these students is essential for creating a good and safe educational and practical environment for ethnic minority students.

Burnout and engagement among PhD students in medicine: the BEeP study.

INTRODUCTION: Using a self-determination theory framework, we investigated burnout and engagement among PhD students in medicine, and their association with motivation, work-life balance and satisfaction or frustration of their basic psychological needs. METHOD: This cross-sectional study was conducted among PhD students at a university medical centre (n = 990) using an electronic survey on background characteristics and validated burnout, engagement, motivation and basic psychological needs questionnaires. Cluster analysis was performed on the burnout subscale scores to find subgroups within the sample which had similar profiles on burnout. Structural equation modelling was conducted on a hypothesized model of frustration of basic psychological needs and burnout. RESULTS: The response rate was 47% (n = 464). We found three clusters/subgroups which were composed of PhD students with similar burnout profiles within the cluster and different profiles between the clusters. Cluster 1 (n = 199, 47%) had low scores on burnout. Clusters 2 (n = 168, 40%) and 3 (n = 55, 13%) had moderate and high burnout scores, respectively, and were associated with low engagement scores. Cluster 3, with the highest burnout scores, was associated with the lowest motivational, engagement, needs satisfaction and work-life balance scores. We found a good fit for the "basic psychological needs frustration associated with burnout" model. DISCUSSION: The most important variables for burnout among PhD students in medicine were lack of sleep and frustration of the basic psychological needs of autonomy, competence and relatedness. These add to the factors found in the literature.

Scaffolding Clinical Reasoning of Health Care Students: A Qualitative Exploration of Clinicians' Perceptions on an Interprofessional Obstetric Ward.

PURPOSE: Interprofessional education (IPE) on a ward supports students to generate interprofessional patient care plans as a means to learn about the roles, responsibilities, and clinical reasoning of other professions. We investigated how clinicians guide the clinical reasoning of students from their own and other professions and whether clinicians from nursing, midwifery, and medicine could scaffold students from all professions, that is, by providing just-in-time and tailored support. METHODS: Nine supervising clinicians from medicine, nursing, and midwifery were interviewed and a repeat interview held 3 to 15 weeks later; one nurse supervisor was interviewed only once. Using conventional content analysis, themes were identified inductively. Next, we applied an existing scaffolding framework to conceptualise how clinicians supported the clinical reasoning in an IPE setting. RESULTS: Themes were clinicians' interventions and intentions, results of interventions and of IPE, characteristics of students and clinicians, interactions between clinicians and students, and logistics. Clinicians applied various interventions and expressed several intentions to guide the learning of students from all professions. Clinicians stimulated students' clinical reasoning by structuring meetings, asking students to explain their thoughts to each other and through giving group assignments. Thus, clinicians used peer-assisted learning for the students. By collaborating with other supervising clinicians regarding the form and amount of guidance to give to the students, clinicians applied peer-assisted learning for themselves as well. CONCLUSION: Clinicians can learn to scaffold the clinical reasoning of students from different professions, when they are provided with training, good examples, and structures. An existing scaffolding framework can serve as an overview of aims and interventions to provide just-in-time guidance to students from all professions. The scaffolding framework is useful for training clinicians and for depicting the pedagogical approach for IPE wards.

Bachelor completion and dropout rates of selected, rejected and lottery-admitted medical students in the Netherlands.

BACKGROUND: Evidence for the effectiveness of the selection of medical students is weak. This study aimed to examine the added value of a two-step selection procedure (first step non-academic, second step academic tests) to a pre-university GPA-based lottery procedure. Because previous research has suggested that participation in selection (regardless of the outcome) is a predictor of study success, this study is the first to include students who initially applied for selection, then refrained from (actively) participating in selection and were eventually admitted through lottery. METHODS: Bachelor completion and dropout rates of selected (n = 416) and lottery-admitted students from four cohorts (2006-2009) were compared using logistic regression analysis. Four groups of lottery-admitted students were distinguished: students who were rejected after step 2 (n = 57), were rejected after step 1 (n = 169), withdrew during selection step 1 (n = 42) and students who only applied for lottery (n = 366). Covariates included gender, age, pre-university GPA and cohort. RESULTS: There was a significant association between admission group and obtaining a bachelor degree in three years. Selected students were more likely to obtain a bachelor degree within three years (64.2% versus 51.6%; OR = 1.7) or four years (81.5% versus 74.3%; OR = 1.6) than students who only applied to a lottery (p <  0.05); selected students also seemed more likely to obtain all Year-1 course credits than students who withdrew during step 1 (40.4% versus 21.4%; OR = 2.3; p <  0.05). We found no significant association between dropout and admission groups. Students rejected at step 1 or 2 did not perform significantly different from selected students on any of the outcome measures. CONCLUSIONS: The findings indicated that students at risk for study delay in the preclinical phase in our context were more likely to refrain from applying to a demanding selection procedure when a less demanding alternative was available. We found no significant associations between the non-academic and academic selection steps and bachelor completion and dropout rates. These findings suggest that the presence of the selection was more important than these specific selection components. In follow-up research, we plan to investigate the associations between the admission groups and outcome measures in the clinical phase.

Exploring the timing of medical student research internships: before or after clerkships?

BACKGROUND: The objective of this study was to determine the optimal positioning of the research internship, either before clinical clerkships, at the beginning of the medical Master's programme, or at the end. METHODS: A mixed methods study was carried out. We compared characteristics such as duration, location and grades for internships performed and students' motives for choosing to perform their research internship before or after clinical clerkships. We analysed students' answers to open-ended questions about the reasons for their choices, using the Self-Determination Theory of motivation. RESULTS: Students performing their research internship before clinical clerkships (n = 338) opted more often for an extended internship (OR = 3.16, 95% CI = 2.32-4.31) and an international location (OR = 2.22, 95% CI = 1.46-3.36) compared to those performing their research internships after clinical clerkships (n = 459). Neither the internship grades nor the number of international publications differed significantly between the two groups. Most of the students' motives (102 participants) were classified as extrinsic motivation for research. Students performing research before clinical clerkships more often showed intrinsic motivation for research, students performing research after clinical clerkships were mainly motivated by their career choice. CONCLUSION: To accommodate both groups of students, offering research internships before and after clinical clerkships, is recommended.

Effects of medical school selection on student motivation: a PhD thesis report.

INTRODUCTION: High stakes are involved in student selection, for both medical schools and applicants. This thesis investigated the effects of selection on the medical student population and applicant pool in the Dutch setting. METHODS: This thesis consists of six papers: two quantitative studies, one qualitative study, two mixed methods studies and one perspective paper based on a review of the literature. RESULTS: (1) Compared with a lottery, selection does not result in a student population with better motivation, engagement and performance, both in the clinical and pre-clinical phases of the study. (2) Selection seems to have a temporary stimulating effect on student motivation through enhancing perceived autonomy, competence and relatedness. (3) Applicants adopt a strategic approach, based on the selection procedure, in their choice of medical school. (4) The description of an applicant's motivation is not a reliable and valid tool to assess motivation during selection. (5) Gaining healthcare experience is crucial for applicants' motivation, but inequalities in access to such experiences can demotivate certain student groups from applying to medical school. (6) The gains yielded from selection compared with a lottery seem to be small. Unintentionally induced self-selection among certain groups of students and biased selection procedures may compromise student diversity. DISCUSSION: The added value of selection procedures compared with a weighted lottery for admitting students to medical school is questionable. Students are generally motivated and perform well, irrespective of how they enrolled in medical school. Selection yields only small gains, while student diversity may be hampered.