Systematic review of specialist selection methods with implications for diversity in the medical workforce

Abstract

Purpose There is growing concern that inequities in methods of selection into medical specialties reduce specialist cohort diversity, particularly where measures designed for another purpose are adapted for specialist selection, prioritising reliability over validity. This review examined how empirical measures affect the diversity of specialist selection. The goals were to summarise the groups for which evidence is available, evaluate evidence that measures prioritising reliability over validity contribute to under-representation, and identify novel measures or processes that address under-representation, in order to make recommendations on selection into medical specialties and research required to support diversity. Method In 2020–1, the authors implemented a comprehensive search strategy across 4 electronic databases (Medline, PsychINFO, Scopus, ERIC) covering years 2000–2020, supplemented with hand-search of key journals and reference lists from identified studies. Articles were screened using explicit inclusion and exclusion criteria designed to focus on empirical measures used in medical specialty selection decisions. Results Thirty-five articles were included from 1344 retrieved from databases and hand-searches. In order of prevalence these papers addressed the under-representation of women (21/35), international medical graduates (10/35), and race/ethnicity (9/35). Apart from well-powered studies of selection into general practice training in the UK, the literature was exploratory, retrospective, and relied upon convenience samples with limited follow-up. There was preliminary evidence that bias in the measures used for selection into training might contribute to under-representation of some groups. Conclusions The review did not find convincing evidence that measures prioritising reliability drive under-representation of some groups in medical specialties, although this may be due to limited power analyses. In addition, the review did not identify novel specialist selection methods likely to improve diversity. Nevertheless, significant and divergent efforts are being made to promote the evolution of selection processes that draw on all the diverse qualities required for specialist practice serving diverse populations. More rigorous prospective research across different national frameworks will be needed to clarify whether eliminating or reducing the weighting of reliable pre-selection academic results in selection decisions will increase or decrease diversity, and whether drawing on a broader range of assessments can achieve both reliable and socially desirable outcomes.

Science, ideology, and social progress

“…7 In the absence of other selection methods capable of evaluating the merit of candidates as well as overcoming unfair biases against minorities, the elimination of objective measures in selection may in fact reinforce older biases. 4…”

“…The American Medical Association’s (AMA), ‘Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity: 2021-2023' reorientated its institutional purpose away from the pursuit of professional excellence towards the confrontation of ‘unequal distribution of power and dismantling the systems of power, advantage, and oppression’ that lead to disparate outcomes such as minority under-representation. 4,8…”

Why gender equity matters for psychiatry

“…Equally recent College data showed of those leading mental health services 78.5% are males and 74.3% of Directors of Training are also male. If we are to have a bright future for innovation and research in psychiatry, this must include a commitment not to lose from the 'leaky pipeline' great talent and fresh perspectives that true gender equity will bring to psychiatry 8 . The myriad of barriers for women in medicine as well as in leadership roles are well documented, and no different in psychiatry, but as a profession that prides itself on reflection and understanding of complex systems, we should be well placed to lead in this.…”

Identifying emerging topics in the peer-reviewed literature to facilitate curriculum renewal and development

“…The most prominent example may be the exclusion of female patients from medical trials on the incorrect assumption that they would show the same patterns of illness and treatment response as male patients, leading to many years of suboptimal treatment of cardiovascular disease in women (The Lancet, 2019). Our own work has examined how the unconscious biases of experts may contribute to the underrepresentation of minority groups in specialist medical training (Amos et al, 2021;Roberts et al, 2018).…”