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Purpose of Study: Despite the recognized importance of an ethnically diverse healthcare workforce, the current population of medical specialists does not adequately reflect our society. To further unravel how and at which stages of the career path such diversity loss occurs, we studied ethnic diversity and perceptions of inclusiveness among medical residents., Materials and Methods: We conducted a cross-sectional study among all residents of Erasmus Medical Center in the highly multicultural city of Rotterdam, the Netherlands. An online survey was distributed, in which we inquired about (i) ethnic diversity and (ii) perceptions of inclusivity. The latter outcome includes sense of belonging to the team of supervisors, measured by perceived level of resemblance between residents and their supervisor(s), while focusing on ethnic, cultural, and socioeconomic levels. Residents from different specialties were divided into four groups, according to their medical specialty, i.e., surgical specialties, internal medicine specialties, overall diagnostic/supportive specialties, and family medicine & intellectual disability medicine. Descriptive statistics were applied., Results: From the total of 986 invited residents, 493 (50.0%) participated (median age 32 years [IQR 30-34]), consisting of 346 (70.2%) females. Results showed that the majority, 335 (68.2%) were of Dutch origin, 90 (18.3%) were children of migrants, and 66 (13.4%) were migrants. We observed notable differences across medical specialties, with the highest degree of ethnic diversity in surgical specialties. Except for residents from supportive specialties, residents from other specialties who are (children of) migrants reported significantly more often that they experienced differences on ethnic and/or cultural levels with their supervisors than residents of Dutch origin., Conclusion: While (children of) migrants were underrepresented in this cohort, especially given the demographic distribution of the region of Rotterdam, a comparison of our results with previously published census data on medical students cohorts indicates no substantial loss of ethnic diversity in the transition from medical student to residency. Yet, these groups scored lower on questions related to sense of belonging., Clinical Trial Number: Not applicable., Competing Interests: Declarations. Ethics approval and consent to participate: The study has been approved by the Medical Research Ethics Committee of Erasmus Medical Center, Rotterdam, the Netherlands (MEC-2022-0826). Written informed consent was first obtained from all participants after a written explanation of the study. The participant was shown the questionnaire only after providing consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

To ensure diversity in the healthcare workforce selection committees must select a cohort of students who collectively possess the wide variety of qualities necessary to serve societal needs. In practice, selection procedures primarily focus on predicting academic outcomes, which are currently based on a limited set of qualities, restricting the definition of excellence in healthcare. The authors propose a shift in the design of selection procedures by including additional considerations - student diversity and applicant perception - to select talented students who can fulfil societal needs. The authors explain the importance of incorporating these considerations into the design of selection procedures and challenges that may arise. To overcome the challenges of incorporating student diversity and applicant perception in the design of selection procedures, a new view on alignment between the profession, training and selection is needed. This starts with redefining excellence in the profession with more explicit attention to equity, diversity and inclusion (EDI). The authors argue that by employing an EDI-adjusted model of alignment, selection procedures can enhance academic outcomes, properly recognize the talents of and acknowledge the needs for a diverse future workforce and be perceived as fair by applicants., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Introduction: Applicant perceptions of selection impact motivation and performance during selection, and student diversity. However, in-depth insight into which values underly these perceptions is lacking, creating challenges for aligning selection procedures with applicant perceptions. This qualitative interview study aimed to identify values applicants believe should underlie selection, and how, according to applicants, these values should be used to make specific improvements to selection procedures in undergraduate health professions education (HPE)., Methods: Thirty-one applicants to five undergraduate HPE programs in the Netherlands participated in semi-structured interviews using Appreciative Inquiry, an approach that focuses on what goes well to create vision for improvement, to guide the interviews. Transcriptions were analyzed using thematic analysis, adopting a constructivist approach., Results: Applicants' values related to the aims of selection, the content of selection, and the treatment of applicants. Applicants believed that selection procedures should aim to identify students who best fit the training and profession, and generate diverse student populations to fulfill societal needs. According to applicants, the content of selection should be relevant for the curriculum and profession, assess a comprehensive set of attributes, be of high quality, allow applicants to show who they are, and be adapted to applicants' current developmental state. Regarding treatment, applicants believed that selection should be a two-way process that fosters reflection on study choice, be transparent about what applicants can expect, safeguard applicants' well-being, treat all applicants equally, and employ an equitable approach by taking personal circumstances into account. Applicants mentioned specific improvements regarding each value., Discussion: Applicants' values offer novel insights into what they consider important preconditions for the design of selection procedures. Their suggested improvements can support selection committees in better meeting applicants' needs., (© 2024. The Author(s).)

Introduction: Medical educators aim to understand why students differ in performance and stress. While performance and stress are associated with student demographics, school factors and aspects of self-regulated learning (SRL), it remains unclear how these elements interact within individuals. This multi-cohort study identified SRL profiles among medical students and explored their associations with performance and stress. Additionally, we examined the identified profiles' associations with gender, migration status and assessment policy., Methods: We used latent profile analysis (LPA) to identify profiles on Motivated Strategies for Learning Questionnaire (MSLQ) scores of six cohorts (2014-2019) of Year 1, first semester medical students (n = 1894) in a Dutch medical school. We used nine MSLQ subscales that measure test anxiety (TA), self-efficacy, deep learning, resource management and value. The university's assessment policy varied, demanding students to obtain 100% or 75% of Year 1 credits to remain enrolled. We defined optimal performance as obtaining all credits at the end of Year 1. Two cohorts completed the Perceived Stress Scale (PSS-14, n = 409) in the 2nd semester., Results: We identified three distinct student profiles: 693/1894(36.6%) were classified as TA high SRL high , 661/1894(34.9%) as TA low SRL high and 540/1894(28.5%) as TA moderate SRL low . Females were more likely to belong to TA high SRL high profiles compared to males (effect size [ES] Cramer's V = .13, small). Migration background was not associated with these profiles. The TA high SRL high profile was more prevalent under the 100% assessment policy (ES Cramer's V = .10, negligible). TA low SRL high students demonstrated lower stress levels (PSS = 23.9 out of 56) compared to TA high SRL high students (PSS = 28.7, ES Cohen's d = .62, medium) and TA moderate SRL low students (PSS = 28.2, ES Cohen's d = .51, medium). Performance differed among the three profiles (ES Cramer's V = .16, small): 82.5% optimal performance in the TA low SRL high , 71.9% in the TA high SRL high and 65.2% in the TA moderate SRL low profile., Discussion: Three distinct SRL student profiles associated with gender, academic performance and perceived stress were identified. Test anxiety had additional value in distinguishing subgroups with differential academic performance and stress. These profiles may aid educators to inform personalised support strategies for novice learners., (© 2023 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Student diversity in health professions education (HPE) can be affected by selection procedures. Little is known about how different selection tools impact student diversity across programs using different combinations of traditional and broadened selection criteria. The present multi-site study examined the chances in selection of subgroups of applicants to HPE undergraduate programs with distinctive selection procedures, and their performance on corresponding selection tools. Probability of selection of subgroups (based on gender, migration background, prior education, parental education) of applicants (N = 1935) to five selection procedures of corresponding Dutch HPE undergraduate programs was estimated using multilevel logistic regression. Multilevel linear regression was used to analyze performance on four tools: prior-education grade point average (pe-GPA), biomedical knowledge test, curriculum-sampling test, and curriculum vitae (CV). First-generation Western immigrants and applicants with a foreign education background were significantly less likely to be selected than applicants without a migration background and with pre-university education. These effects did not vary across programs. More variability in effects was found between different selection tools. Compared to women, men performed significantly poorer on CVs, while they had higher scores on biomedical knowledge tests. Applicants with a non-Western migration background scored lower on curriculum-sampling tests. First-generation Western immigrants had lower CV-scores. First-generation university applicants had significantly lower pe-GPAs. There was a variety in effects for applicants with different alternative forms of prior education. For curriculum-sampling tests and CVs, effects varied across programs. Our findings highlight the need for continuous evaluation, identifying best practices within existing tools, and applying alternative tools., (© 2023. The Author(s).)

Recent work revealed that ethnic minority gp-trainees are more at risk of underperformance than their majority peers. We argue that causes for underperformance can be identified from two perspectives, namely that of the trainees ('them') and that of the assessors and the institution ('us'). Potential impeding factors from the student perspective include lack of practical clinical skills and differences in communication styles. At the level of the assessors, it is important to consider in-group bias and individual assessors' perceptions and preferences. Finally, possible factors at the institutional level are type of evaluation system used and organizational culture. Questions are raised regarding the existence of one golden rule for doctor-patient communication and the role of the hidden curriculum in negatively influencing social and academic outcomes for minority trainees. The urge is for creating an inclusive learning environment ensuring psychological safety and talent usage for all our future doctors.

Background: The prevalence of medical students' mental distress is high. While schools apply various methods to select a well-performing and diverse student population, little is known about the association between different selection methods and the well-being of these students during medical school. The present retrospective multi-cohort study assessed whether students selected by high grades, assessment, or weighted lottery showed different stress perception levels in Year-1 of medical school., Methods: Of 1144 Dutch Year-1 medical students, 650 (57%) of the cohorts 2013, 2014, and 2018 who were selected by high grades, assessment, or weighted lottery completed a stress perception questionnaire (PSS-14). A multilevel regression analysis assessed the association between selection method (independent variable) and stress perception levels (dependent variable) while controlling for gender and cohort. In a post-hoc analysis, academic performance (optimal vs. non-optimal) was included in the multilevel model., Results: Students selected by assessment (B = 2.25, p < .01, effect size (ES) = small) or weighted lottery (B = 3.95, p < .01, ES = medium) had higher stress perception levels than students selected by high grades. Extending the regression model with optimal academic performance (B=-4.38, p < .001, ES = medium), eliminated the statistically significant difference in stress perception between assessment and high grades and reduced the difference between weighted lottery and high grades from 3.95 to 2.45 (B = 2.45, p < .05, ES = small)., Conclusions: Selection methods intended to create a diverse student population - assessment and lottery - are associated with higher stress perception levels in Year-1 of medical school. These findings offer medical schools insights into fulfilling their responsibility to take care of their students' well-being., (© 2023. The Author(s).)

Background: Medical schools are reported to be less accessible to students with non-traditional backgrounds. These students face barriers when applying for and transitioning to medical school, which may be reduced by offering free preparatory activities. By equalizing access to resources, these activities are expected to reduce disparities in selection outcomes and early academic performance. In the present study, four free institutionally-provided preparatory activities were evaluated by comparing the demographic composition of participating and non-participating applicants. Additionally, the association between participation and selection outcomes and early academic performance was investigated for subgroups (based on sex, migration background and parental education)., Methods: Participants were applicants to a Dutch medical school in 2016-2019 (N = 3592). Free preparatory activities included Summer School (N = 595), Coaching Day (N = 1794), Pre-Academic Program (N = 217), and Junior Med School (N = 81), supplemented with data on participation in commercial coaching (N = 65). Demographic compositions of participants and non-participants were compared using chi-squared tests. Regression analyses were performed to compare selection outcomes (curriculum vitae [CV], selection test score, probability of enrolment) and early academic performance (first-course grade) between participants and non-participants of demographic subgroups, controlling for pre-university grades and participation in other activities., Results: Generally, no differences in sociodemographic compositions of participants and non-participants were found, but males participated less often in Summer School and Coaching Day. Applicants with a non-Western background participated less often in commercial coaching, but the overall participation rate was low and participation had negligible effects on selection outcomes. Participation in Summer School and Coaching Day were stronger related with selection outcomes. In some cases, this association was even stronger for males and candidates with a migration background. After controlling for pre-university grades, none of the preparatory activities were positively associated with early academic performance., Conclusions: Free institutionally-provided preparatory activities may contribute to student diversity in medical education, because usage was similar across sociodemographic subgroups, and participation was positively associated with selection outcomes of underrepresented and non-traditional students. However, since participation was not associated with early academic performance, adjustments to activities and/or curricula are needed to ensure inclusion and retention after selection., (© 2023. The Author(s).)

Background: An increase in the demand for general practitioners is expected in many countries, but only a minority of medical students consider a career in general practice. More detailed and up-to-date knowledge about medical student's perception of general practice would be helpful for efforts to encourage medical students to consider a career in general practice., Methods: We performed a cross-sectional single center survey among Dutch medical students to evaluate their perception of general practice at three different stages in their study: Ba1: first-year bachelor students; Ba3: third-year bachelor students; Ma3: third-year master students. The impact of different factors on their attitudes and perceptions was quantified. A multivariate logistic regression was performed with 'interest in general practice' as the outcome variable., Results: The median age for Ba1 was 18 (IQR: 18-19) and 71.5% were female, for Ba3 the median age was 20 (IQR: 20-21) and 70.6% were female and for Ma3 the median age was 25 years (IQR: 24-26) and 73.3% were female. On average, 31.2% of the respondents had a migration background. The mean response rate for this study was 77.1%. Of the participating Ba1 students (n = 340) only 22.4% considered working as a GP after medical school; for Ba3 students (n = 231) this percentage was 33.8%, and for Ma3 students (n = 210) it was significantly higher at 70.5%; in the final multivariate model this corresponded to an odds ratio (OR) of 4.3 (95%-CI:2.6-6.9) compared to Ba1 students. The strongest predictor in the final model was the opinion that general practice provides a pleasant working environment (OR 9.5; 95%-CI: 6.2-14.5)., Conclusion: This study showed that multiple factors are significantly related to medical students' interest in general practice. Although students believed that general practice does not have a high status within the medical profession, they acknowledged the social importance and the pleasant working environment of general practice. Knowledge obtained in this study can be used when designing a medical curriculum or a general practice course., (© 2023. The Author(s).)

Background: Medical schools are challenged to guard student wellbeing given the potential negative impact of the COVID-19 outbreak combined with an already high prevalence of mental distress. Although social support is generally associated with less crisis-induced stress, it is unknown whether this applies to medical students during the COVID-19 outbreak., Objectives: The impact of the COVID-19 outbreak on perceived stress of medical students was assessed by comparing their perceived stress levels during the outbreak to both their own baseline and the previous cohort's pre-COVID-19 stress levels. Then, the association between social support and stress during the COVID-19 outbreak was assessed., Methods: Dutch Year-1 medical students of cohort 2019 (n = 99) completed the 14-item Perceived Stress Scale (PSS-14) at two time points: baseline (pre-COVID-19) and final measurement (COVID-19). Social support-emotional-informational support and club membership-was assessed during the final measurement. PSS and social support scores were compared to similar measurements of cohort 2018 (n = 196). Students' baseline stress levels, gender, and study performance were controlled for when comparing final stress levels., Results: In cohort 2018 (pre-COVID-19), students' perceived stress levels did not differ significantly between the baseline and final measurements. Additionally, baseline stress levels of the two cohorts (2018 and 2019) were not found to be significantly different. Cohort 2019's final stress levels (COVID-19) were significantly higher compared to their baseline stress levels (paired t-test: t = 6.07, p < .001) and cohort 2018's final stress levels (linear regression: B = 4.186, p < .001). Only during the COVID-19 outbreak higher social support levels-i.e., emotional-informational support (B = -0.75, p < .001) and club membership (B = -3.68, p < .01)-were associated with lower stress levels., Conclusions: During the COVID-19 outbreak, medical students' perceived stress levels were higher-especially for students with lower social support levels. Our results suggest that medical schools should optimize social support to minimize crisis-induced stress., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Broks et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Medically unexplained symptoms (MUS) are highly prevalent and remain challenging in healthcare and medical education, along with the increase in the importance of intercultural issues regarding MUS. However, less is known about the challenges of professionally addressing patients with MUS in the interprofessional and intercultural contexts. Thus, the present study aims to provide the first exploration of the experiences of medical specialists regarding treating MUS in intercultural contexts and inputs for training development on the intercultural aspects of MUS., Methods: Three focus groups (total n = 13) consisting of medical specialists from a Hungarian university who were teaching at the medical faculty in intercultural settings and also worked for the university health services were interviewed. The topics covered the participants' personal experiences on addressing MUS and the challenges of intercultural communication and the intercultural educational context. Thematic analysis was used to yield a qualitative account of the interviews as guided by the research questions., Results: Representing the different aspects of medical specialists, the study identified three main themes in the experiences of medical specialists, namely, 1) the need to adapt to the personal world of patients and search for common frames to understand MUS, 2) the need to discover methods for adapting to cultural differences and 3) the need to enhance the interprofessional coordination of knowledge and practices., Conclusions: The results are in line with the distinct conclusions of previous studies. Moreover, an integrated educational program on the intercultural aspects of MUS may address the main themes separately and, subsequently, support their integration. Therefore, the study discusses the manner in which an integrated educational program on the intercultural aspects of MUS may address the needs recognized in these aspects., (© 2022. The Author(s).)

Introduction: Implicit biases of health professionals could cause biased judgements. Many anti-bias interventions seem to be ineffective, and some even counterproductive. People tend to be compliant to standards describing what the majority of people finds or does, and this could cause people to think in a stereotype-consistent manner. This study examines whether descriptive social norms such as 'the majority of people have stereotypes' (majority message), as often stated in interventions, actually increase people's stereotypes. To examine the effect of descriptive social norms (Hypothesis 1) and the effect of individual perceptions and preferences (Hypothesis 2a and 2b) on stereotypical expressions towards medical students., Methods: First, we determined which ethic stereotypes regarding medical students prevail in Dutch medical education (N = 52). Next, two similar randomised controlled trials, both with teachers and students, were carried out (N = 158 and N = 123, respectively), one with an East Asian student picture (ethnic minority) and one with a native Dutch student picture (ethnic majority). Participants were randomly assigned to either a majority-message, minority-message or no-message condition, and rated the presented minority or majority picture on specific stereotypical features. Subsequently, participants described a typical day of that same student's life. These descriptions were rated for stereotypicality by two independent raters, who were blind for condition and stimulus. Inclusive work environment (IWC) and social dominance orientation (SDO) of participants were measured as indicators of individual perceptions and preferences., Results: Stereotypes were expressed towards both picture stimuli, yet message condition did not affect stereotypical expressions. SDO positively related to stereotypical expressions towards the East Asian student, whereas IWC positively related to stereotypical expressions towards the native Dutch student., Conclusion: Interventions do not unintentionally increase stereotypes by communicating what the majority of people thinks or does. Individual perceptions and preferences are predictive of stereotypes, whereas descriptive social norms are not., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Ethnic minority students find that their ethnicity negatively affects the evaluation of their capacities and their feelings in medical school. This study tests whether ethnic minority and majority students differ in their 'self-regulatory focus' in clinical training, that is, their ways to approach goals, due to differences in social learning experiences. Self-regulatory focus consists of a promotion and prevention focus. People who are prone to stereotypes and unfair treatments are more likely to have a prevention focus and conceal certain identity aspects. The objectives of the study are to test whether ethnic minority students, as compared with ethnic majority students, are equally likely to have a promotion focus, but more likely to have a prevention focus in clinical training due to more negative social learning experiences (Hypothesis 1), and whether the relationship between student ethnicity and clinical evaluations can be explained by students' gender, social learning experiences, self-regulatory focus and impression management (Hypothesis 2)., Methods: Survey and clinical evaluation data of 312 (71.2% female) clerks were collected and grouped into 215 ethnic majority (69.4%) and 95 ethnic minority students (30.6%). Students' social learning experiences were measured as perceptions of unfair treatment, trust in supervisors and social academic fit. Self-regulatory focus (general and work specific) and impression management were also measured. A parallel mediation model (Hypothesis 1) and hierarchical multiple regression analyses were used (Hypothesis 2)., Results: Ethnic minority students had higher perceptions of unfair treatment and lower trust in their supervisors in clinical training. They were more prevention focused in clinical training, but this was not mediated by having more negative social learning experiences. Lower clinical evaluations for ethnic minority students were unexplained. Promotion focus in clinical training and trust in supervisors positively relate to clinical grades., Conclusion: Student ethnicity predicts social learning experiences, self-regulatory focus and grades in clinical training. The hidden curriculum plausibly plays a role here., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Medical students' clinical competencies are customarily assessed using convenience samples of performance from real practice. The question is how these convenience samples can be turned into purposeful samples to extrapolate students' overall competency profile at the end of medical school, particularly given the context specificity of clinical performance. In this paper, we will address this issue of inferring signs from samples using insights from the discipline of psychology., Theoretical Perspective: We adapted Smith's theory of predictor validity of universals, occupationals and relationals to the context of clinical competency assessment. Universals are characteristics required by all working individuals and therefore not context dependent. Occupationals refer to characteristics required by certain jobs but not others and therefore are dependent on task-related features of an occupation. Relationals are required in a specific organisational context with habitual ways of working together., Application: Through seven propositions, we assert that generalising from samples of assessed clinical competencies during clerkships to generic competencies (i.e., signs) is dependent on whether characteristics are universals, occupationals and relationals, with universals most and relationals least generalisable., Conclusion: When determining what types of ratings to use to evaluate medical student competence, medical education has shown too little nuance in considering the degree to which particular characteristics are likely to be generalisable, approaching the issue in an all-or-none manner. Smith's distinction between universals, occupationals and relationals offers a promising way forward that has implications for assessment, student selection and career choice., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Since the pathophysiology of medically unexplained symptoms (MUS) remains unclear, healthcare providers often struggle with these patients, especially with a different ethnic and/or cultural background. These challenges are insufficiently addressed in their training and in the organisation of care., Aim: To improve healthcare provider-patient interaction focused on MUS patients in general and in ethnic minorities and refugees in particular through a systematic review of syndromal definitions and epidemiology and organisation of care of MUS patients., Methods: Screening of PubMed, Web of Science, Cinahl and Cochrane Library on the keywords 'Medical unexplained (physical) symptoms (MUPS)', 'Somatoform disorder', 'Functional syndrome', 'Diversity', 'Migrants', 'Ethnicity', 'Care models', 'Medical education', 'Communication skills', 'Health literacy'., Results: Different case definitions result in markedly different epidemiological estimates for MUS patients. Nevertheless, they are prevalent in a wide range of healthcare settings. Literature offers evidence of the effectiveness of structural frameworks in approaching MUS patients. Organisation of MUS care needs to transcend different levels of care: specialist tertiary and secondary care and primary care involving different qualifications of caregivers need to be aligned., Conclusion: The systematic review identified significant gaps and shortcomings in organisation of care. These need to be addressed in order to improve outcomes., (© 2021 The Authors. International Journal of Clinical Practice published by John Wiley & Sons Ltd.)

Context: Medical schools seek for measures to improve their students' study progress and are responsible for a diverse student population., Objectives: The effect of a stricter academic dismissal (AD) policy in medical school on short-term and long-term study progress was investigated in a longitudinal cohort study. In addition, differential effects for subgroups were assessed by intersecting gender, ethnicity and prior education (intersectional framework)., Methods: Participants were first-year Bachelor students enrolled in 2011 to 2016 in a Dutch medical school. For cohorts 2011-2013, the AD policy consisted of a minimum of 67% of Year-1 credits required to remain enrolled (67%-policy, n = 1189), and for cohorts 2014-2016, this bar was raised to 100% of Year-1 credits (100%-policy, n = 1233). Outcome measures on study progress were Year-1 completion and dropout (short term) and Bachelor completion in three and four years (long term)., Results: Overall, Year-1 completion rates increased under the 100%-policy compared to the 67%-policy (OR = 2.50, 95%-CI:2.06-3.03, P < .001). Yet, this increase was not present for students with non-standard prior education - except for males with a migration background (OR = 7.19, 95%-CI:2.33-25.73, P < .01). The dropout rate doubled under the 100%-policy (OR = 2.41, 95%-CI:1.68-3.53, P < .001). Mainly students with standard prior education dropped out more often (OR = 3.68, 95%-CI:2.37-5.89, P < .001), except for males with a migration background. Bachelor completion rates after three and four years were not positively affected by the 100%-policy. Notably, females without a migration background and with non-standard prior education suffered from the 100%-policy regarding Bachelor completion after three years (OR = 0.29, 95%-CI:0.11-0.76, P < .05)., Conclusions: Despite increased dropout rates, the stricter AD policy improved Year-1 completion rates - especially for under-represented subgroups, thereby improving study progress without harming student diversity on the short term. However, these positive effects did not hold regarding Bachelor completion rates indicating that long-term effects require higher performance standards throughout the Bachelor, which in turn may harm other subgroups and thereby student diversity., (© 2021 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

The diversity of modern society is often not represented in the medical workforce. This might be partly due to selection practices. We need to better understand decision-making processes by selection committees in order to improve selection procedures with regard to diversity. This paper reports on a qualitative study with a socio-constructivist perspective conducted in 2015 that explored how residency selection decision-making occurred within four specialties in two regions in the Netherlands. Data included transcripts of the decision-making meetings and of one-on-one interviews with committee members before and after the group decision-making meetings. Candidates struggled to portray themselves favorably as they had to balance playing by the rules and being authentic; between fitting in and standing out. Although admissions committees had a welcoming stance to diversity, their practices were unintentionally preventing them from hiring underrepresented minority (URM) candidates. While negotiating admissions is difficult for all candidates, it is presumably even more complicated for URM candidates. This seems to be having a negative influence on attaining workforce diversity. Current beliefs, which make committees mistakenly feel they are acting fairly, might actually justify biased practices. Awareness of the role of committee members in these processes is an essential first step.

Context: Medical schools are challenged to create academic environments that stimulate students to improve their study progress without compromising their well-being., Objectives: This prospective comparative cohort study investigated the effects of raising Year-1 standards on academic performance and on students' chronic psychological and biological stress levels., Methods: In a Dutch medical school, students within the last Bachelor's degree cohort (n = 410) exposed to the 40/60 (67%) credit Year-1 standard (67%-credit cohort) were compared with students within the first cohort (n = 413) exposed to a 60/60 (100%) credit standard (100%-credit cohort). Main outcome measures were Year-1 pass rate (academic performance), mean score on the Perceived Stress Scale (PSS, psychological stress) and hair cortisol concentration (HCC, biological stress)., Results: Year-1 pass rates were significantly higher in the 100%-credit cohort (odds ratio [OR] 4.65). Interestingly, there was a significant interaction effect (OR 0.46), indicating that raising the standard was more effective for male than for female students. PSS scores (n = 234 [response rate [RR]: 57%] and n = 244 [RR: 59%] in the 67%- and 100%-credit cohorts, respectively) were also significantly higher in the 100%-credit cohort (F (1,474)  = 15.08, P < .001). This applied specifically to female students in the 100%-credit cohort. Levels of HCC (n = 181 [RR: 44%] and n = 162 [RR: 39%] respectively) did not differ between cohorts, but were significantly higher in female students (F (1,332)  = 7.93, P < .01). In separate models including cohort and gender, both PSS score (OR 0.91) and HCC (OR 0.38) were significantly associated with Year-1 performance. Only students with both high PSS scores and high HCC values were significantly at risk of lower Year-1 pass rates (OR 0.27), particularly male students., Conclusions: Raising the Year-1 performance standard increased academic performance, most notably in male students. However, it also increased levels of perceived stress, especially in female students. In particular, the combination of high levels of perceived stress and biological stress, as measured by long-term cortisol, was related to poor academic performance. The study suggests a relationship between raising performance standards and student well-being, with differential effects in male and female students., (© 2020 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Ethnicity-related differences in clinical grades exist. Broad sampling in assessment of clinical competencies involves multiple assessments used by multiple assessors across multiple moments. Broad sampling in assessment potentially reduces irrelevant variances and may therefore mitigate ethnic disparities in clinical grades., Objectives: Research question 1 (RQ1): to assess whether the relationship between students' ethnicity and clinical grades is weaker in a broadly sampled versus a global assessment. Research question 2 (RQ2): to assess whether larger ethnicity-related differences in grades occur when supervisors are given the opportunity to deviate from the broadly sampled assessment score., Methods: Students' ethnicity was classified as Turkish/Moroccan/African, Surinamese/Antillean, Asian, Western, and native Dutch. RQ1: 1667 students (74.3% native Dutch students) were included, who entered medical school between 2002 and 2004 (global assessment, 818 students) and between 2008 and 2010 (broadly sampled assessment, 849 students). The main outcome measure was whether or not students received ≥3 times a grade of 8 or higher on a scale from 1 to 10 in five clerkships. RQ2: 849 students (72.4% native Dutch students) were included, who were assessed by broad sampling. The main outcome measure was the number of grade points by which supervisors had deviated from broadly sampled scores. Both analyses were adjusted for gender, age, (im)migration status and average bachelor grade., Results: Research question 1: ethnicity-related differences in clinical grades were smaller in broadly sampled than in global assessment, and this was also seen after adjustments. More specifically, native Dutch students had reduced probabilities (0.87-0.65) in broadly sampled as compared with global assessment, whereas Surinamese (0.03-0.51) and Asian students (0.21-0.30) had increased probabilities of having ≥3 times a grade of 8 or higher in five clerkships. Research question 2: when supervisors were allowed to deviate from original grades, ethnicity-related differences in clinical grades were reintroduced., Conclusions: Broadly sampled assessment reduces ethnicity-related differences in grades., (© 2019 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: This study examined the influence of two Situational Judgement Test (SJT) design features (response instructions and response format) on applicant perceptions. Additionally, we investigated demographic subgroup differences in applicant perceptions of an SJT., Methods: Medical school applicants (N = 372) responded to an online survey on applicant perceptions, including a description and two example items of an SJT. Respondents randomly received one of four SJT versions (should do-rating, should do-pick-one, would do-rating, would do-pick-one). They rated overall favourability and items on four procedural justice factors (face validity, applicant differentiation, study relatedness and chance to perform) and ease-of-cheating. Additionally, applicant perceptions were compared for subgroups based on gender, ethnic background and first-generation university status., Results: Applicants rated would-do instructions as easier to cheat than should-do instructions. Rating formats received more favourable judgements than pick-one formats on applicant differentiation, study-relatedness, chance to perform and ease of cheating. No significant main effect for demographic subgroup on applicant perceptions was found, but significant interaction effects showed that certain subgroups might have more pronounced preferences for certain SJT design features. Specifically, ethnic minority applicants - but not ethnic majority applicants - showed greater preference for should-do than would-do instructions. Additionally, first-generation university students - but not non-first-generation university students - were more favourable of rating formats than of pick-one formats., Conclusions: Findings indicate that changing SJT design features may positively affect applicant perceptions by promoting procedural justice factors and reducing perceived ease of cheating and that response instructions and response format can increase the attractiveness of SJTs for minority applicants.

Context: Despite their widespread use in medical school selection, there remains a lack of clarity on exactly what situational judgement tests (SJTs) measure., Objectives: We aimed to develop an SJT that measures integrity by combining critical incident interviews (inductive approach) with an innovative deductive approach. The deductive approach guided the development of the SJT according to two established theoretical models, of which one was positively related to integrity (honesty-humility [HH]) and one was negatively related to integrity (cognitive distortions [CD]). The Integrity SJT covered desirable (HH-based) and undesirable (CD-based) response options. We examined the convergent and discriminant validity of the Integrity SJT and compared the validity of the HH-based and CD-based subscores., Methods: The Integrity SJT was administered to 402 prospective applicants at a Dutch medical school. The Integrity SJT consisted of 57 scenarios, each followed by four response options, of which two represented HH facets and two represented CD categories. Three SJT scores were computed, including a total, an HH-based and a CD-based score. The validity of these scores was examined according to their relationships with external integrity-related measures (convergent validity) and self-efficacy (discriminant validity)., Results: The three SJT scores correlated significantly with all integrity-related measures and not with self-efficacy, indicating convergent and discriminant validity. In addition, the CD-based SJT score correlated significantly more strongly than the HH-based SJT score with two of the four integrity-related measures., Conclusions: An SJT that assesses the ability to correctly recognise CD-based response options as inappropriate (i.e. what one should not do) seems to have stronger convergent validity than an SJT that assesses the ability to correctly recognise HH-based response options as appropriate (i.e. what one should do). This finding might be explained by the larger consensus on what is considered inappropriate than on what is considered appropriate in a challenging situation. It may be promising to focus an SJT on the ability to recognise what one should not do., (© 2018 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Optimising student learning and academic performance is a continuous challenge for medical schools. The assessment policy may influence both learning and performance. Previously, the joint contribution of self-regulated learning (SRL) and participation in scheduled learning activities towards academic performance has been reported. However, little is known about the relationships between SRL, participation and academic performance under different assessment policies., Objectives: The goal of this study was to investigate differences in average scores of SRL, participation and academic performance of students under two assessment policies: (i) a conjunctive lower stakes, lower performance standard (old) assessment policy and (ii) a compensatory higher stakes, higher performance standard (new) assessment policy. In addition, this research investigated whether the relationships between academic performance, SRL and participation are similar across both assessment policies., Methods: Year-1 medical students (i) under the old assessment policy (n = 648) and (ii) under the new assessment policy (n = 529) completed the Motivated Strategies for Learning Questionnaire on SRL, and additional items on participation. Year-1 performance was operationalised as students' average Year-1 course examination grades. manova and structural equation modelling were used for analyses., Results: Generally, students under the new assessment policy showed significantly higher Year-1 performance, SRL and participation, compared with students under the old assessment policy. The relationships between Year-1 performance, SRL and participation were similar across assessment policies., Conclusions: This study indicates that the higher academic performance under a compensatory higher stakes, higher performance standard assessment policy, results from higher SRL and participation, but not from altered relationships between SRL, participation and performance. In sum, assessment policies have the potential to optimise student learning and performance., (© 2017 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Context: Thirty years ago, it was suggested in the Edinburgh Declaration that medical school applicants should be selected not only on academic, but also on non-academic, attributes. The main rationale behind extending medical school selection procedures with the evaluation of (non-academic) personal qualities is that this will lead to the selection of students who will perform better as a doctor than those who are selected on the basis of academic measures only. A second rationale is the expectation that this will lead to a representative health workforce as a result of reduced adverse impact. The aims of this paper are (i) to describe what can be learned about the use of selection criteria other than grades from over 15 years of Dutch experience and (ii) to summarise current knowledge on the issue of adverse impact in relation to non-grades-based selection., Methods: A narrative review was undertaken of the (published) evidence that has resulted from non-grades-based school-specific selection procedures in the Netherlands and from recent explorations of the effect of the use of non-grades-based selection criteria on student diversity., Results: The Dutch evidence is grouped into five key themes: the effect of participation in voluntary selection procedures, the assessment of pre-university extracurricular activities, the use of work samples, Dutch experiences with situational judgement tests and the effects of changing circumstances. This is followed by several lessons learned for medical schools that aim to increase their student diversity., Conclusion: Over the last 30 years, important steps towards reliable and valid methods for measuring non-academic abilities have been taken. The current paper describes several lessons that can be learned from the steps taken in the Dutch context. The importance of sharing evidence gathered around the globe and building on this evidence to reach our goal of predicting who will be a good doctor is acknowledged., (© 2017 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Not all students cope successfully with the demands of medical school, and students' struggles may result in study delay or dropout. To prevent these outcomes, medical schools need to identify students who are experiencing academic difficul ties and provide them with timely interventions through access to support programs. Although the importance of early identification and intervention is well recognized, less is known about successful strategies for identifying and supporting struggling students.Building on the literature and their own empirical findings, the authors propose an integrated, school-wide model for medical student success comprising a continuum of academic and behavioral support. This Four-Tier Continuum of Academic and Behavioral Support (4T-CABS) model focuses on improving both academic and behavioral outcomes by offering support for students at four levels, which range from adequate instruction for all, to targeted small-group interventions, to individualized support, and also include exit support for students who might be better off in another degree program. Additionally, medical schools should provide both academic and behavioral support; set high, yet realistic expectations and clearly communicate these to students; and intervene early, which requires timely identification of at-risk students who would benefit from the different types and tiers of support. Finally, interventions should be evidence based and fit the needs of the identified groups of students. The authors argue that adopting the core principles of the 4T-CABS model will enable medical schools to maximize academic engagement and performance for all students.

Background: The proportion of medical doctors involved in research activities is declining. Undergraduate medical research programs are positively associated with medical students' research interest. Scientific pre-university programs (SPUPs) outside the medical domain are also positively associated with research interest, but have not been related to the shortage of clinician-scientists. This study examined the effect of an SPUP on medical students' research interest., Methods: This study was conducted at a Dutch medical school. Medical students in all years who had participated in an SPUP and first-year master students who had not participated in an SPUP were invited to fill out an online survey on extracurricular activities and future career interests. SPUP participants were compared with three groups of non-participants: (i) an unmatched group, (ii) a group matched on gender and pre-university Grade Point Average (pu-GPA) and (iii) a group matched on gender and first-year GPA, one to five years after finishing the SPUP. Participants evaluated the SPUP through ratings of statements about the program., Results: Two-hundred forty medical students, including 71 SPUP participants responded to the survey. SPUP participants participated significantly more often in the Honors class (i.e., extracurricular educational program for high-performing students), gained significantly more often extracurricular research experience, enrolled significantly more often in the Research master (i.e., research training program parallel to the clinical master program) and obtained significantly more often a scholarship than unmatched non-SPUP participants. Using a non-SPUP group matched on gender and pu-GPA reduced the effect size of the significant differences in Honors class participation, Research master participation and scholarship obtainment. Using a non-SPUP group matched on gender and first-year GPA rendered the significant difference in Research master participation and scholarship obtainment insignificant. Significantly more SPUP participants than unmatched non-SPUP participants preferred a combination of clinical care and research in their future career. Using a non-SPUP group matched on gender and either pu-GPA or first-year GPA did not change the effect size of this significant difference., Conclusions: These findings demonstrate the potential value of an SPUP in increasing the number of medical students with research interest and as a policy measure to help to alleviate the shortage of clinician-scientists.

Worldwide, virus infections are responsible for many diseases in terms of morbidity and mortality. Vaccinations and therapies are only available for relatively few virus infections and not always where they are needed. However, knowledge of transmission routes can prevent virus infection. In the context of this study, we measured the effects of a secondary school education module, named Viruskenner, on knowledge, attitude, and risk behavior as these relate to virus infections. A nonrandomized intervention study was conducted between April and August 2015 to assess the effect of this 2-month education module on knowledge, attitude, and behavior of 684 secondary school students in the Netherlands, Suriname, and Indonesia. For the Netherlands, a control group of a further 184 students was added. Factor analysis was performed on questions pertaining to attitude and behavior. Comparative analyses between pre- and posttest per country were done using multiple linear regression, independent sample T-tests, and one-way analysis of variance. These showed a significant increase in knowledge about virus infections and the prevention of infectious diseases among the Dutch and Surinamese groups, whereas a trend of increased knowledge was evident among the Indonesian participants. The Dutch control group showed an overall decrease in knowledge. Regression analyses showed that there was a significant interaction effect between participation and time on knowledge, attitude, and awareness and behavior and risk infection. Attitudes improved significantly in the intervention group. Pearson correlation coefficients between knowledge, attitude, and behavior were found to be positive.

Several medical schools include candidates' extracurricular activities in their selection procedure, with promising results regarding their predictive value for achievement during the clinical years of medical school. This study aims to reveal whether the better achievement in clinical training of students selected on the basis of their extracurricular activities could be explained by persistent participation in extracurricular activities during medical school (msECAs). Lottery-admitted and selected student admission groups were compared on their participation in three types of msECAs: (1) research master, (2) important board positions or (3) additional degree programme. Logistic regression was used to measure the effect of admission group on participation in any msECA, adjusted for pre-university GPA. Two-way ANCOVA was used to examine the inter-relationships between admission group, participation in msECAs and clerkship grade, with pre-university GPA as covariate. Significantly more selected students compared to lottery-admitted students participated in any msECA. Participation in msECAs was associated with a higher pre-university GPA for lottery-admitted students only, whereas participation in msECAs was associated with higher clerkship grades for selected students only. These results suggest that persistent participation in extracurricular activities of selected students favours better clinical achievement, supporting the inclusion of ECAs in the selection procedure. More insight in the rationale behind participation in extracurricular activities during medical school may explain differences found between lottery-admitted and selected students.

Situational Judgment Tests (SJTs) are increasingly used for medical school selection. Scoring an SJT is more complicated than scoring a knowledge test, because there are no objectively correct answers. The scoring method of an SJT may influence the construct and concurrent validity and the adverse impact with respect to non-traditional students. Previous research has compared only a small number of scoring methods and has not studied the effect of scoring method on internal consistency reliability. This study compared 28 different scoring methods for a rating SJT on internal consistency reliability, adverse impact and correlation with personality. The scoring methods varied on four aspects: the way of controlling for systematic error, and the type of reference group, distance and central tendency statistic. All scoring methods were applied to a previously validated integrity-based SJT, administered to 931 medical school applicants. Internal consistency reliability varied between .33 and .73, which is likely explained by the dependence of coefficient alpha on the total score variance. All scoring methods led to significantly higher scores for the ethnic majority than for the non-Western minorities, with effect sizes ranging from 0.48 to 0.66. Eighteen scoring methods showed a significant small positive correlation with agreeableness. Four scoring methods showed a significant small positive correlation with conscientiousness. The way of controlling for systematic error was the most influential scoring method aspect. These results suggest that the increased use of SJTs for selection into medical school must be accompanied by a thorough examination of the scoring method to be used.

Medical schools are increasingly faced with a more diverse student population. Generally, ethnic minority students are reported to underperform compared with those from the ethnic majority. However, there are inconsistencies in findings in different types of examinations. Additionally, little is known about the performance of first-generation university students and about performance differences across ethnic minority groups. This study aimed to investigate underperformance across ethnic minority groups and by first-generation university students in different types of written tests and clinical skills examinations during pre-clinical training. A longitudinal prospective cohort study of progress on a 3-year Dutch Bachelor of Medicine course was conducted. Participants included 2432 students who entered the course over a consecutive 6-year period (2008-2013). Compared with Dutch students, the three non-Western ethnic minority groups (Turkish/Moroccan/African, Surinamese/Antillean and Asian) underperformed in the clinical problem solving tests, the language test and the OSCEs. Findings on the theoretical end-of-block tests and writing skills tests, and results for Western minority students were less consistent. Age, gender, pre-university grade point average and additional socio-demographic variables (including first-generation university student, first language, and medical doctor parent) could explain the ethnicity-related differences in theoretical examinations, but not in language, clinical and writing skills examinations. First-generation university students only underperformed in the language test. Apparently, underperformance differs both across ethnic subgroups and between different types of written and clinical examinations. Medical schools should ensure their assessment strategies create a level playing field for all students and explore reasons for underperformance in the clinical and writing skills examinations.

Medical schools all over the world select applicants using non-cognitive and cognitive criteria. The predictive value of these different types of selection criteria has however never been investigated within the same curriculum while using a control group. We therefore set up a study that enabled us to compare the academic performance of three different admission groups, all composed of school-leaver entry students, and all enrolled in the same Bachelor curriculum: students selected on non-cognitive criteria, students selected on cognitive criteria and students admitted by lottery. First-year GPA and number of course credits (ECTS) at 52 weeks after enrollment of non-cognitive selected students (N = 102), cognitive selected students (N = 92) and lottery-admitted students (N = 356) were analyzed. In addition, chances of dropping out, probability of passing the third-year OSCE, and completing the Bachelor program in 3 years were compared. Although there were no significant differences between the admission groups in first-year GPA, cognitive selected students had obtained significantly more ECTS at 52 weeks and dropped out less often than lottery-admitted students. Probabilities of passing the OSCE and completing the bachelor program in 3 years did not significantly differ between the groups. These findings indicate that the use of only non-cognitive selection criteria is not sufficient to select the best academically performing students, most probably because a minimal cognitive basis is needed to succeed in medical school.

Objective: To investigate underperformance across ethnic minority groups and by first-generation university students in different types of examinations during pre-clinical training., Design: Prospective cohort study, Methods: Participants included Erasmus MC students from the 2008-2013 cohorts (n=2432). Outcome measures were pass/fail on three types of written examinations: 1) theoretical knowledge: clinical problem solving tests (CPSTs) (Year 1-3) and end-of-block tests (Year 1c2-c3), 2) language skills test (Year 1) and 3) writing skills tests (Year 1-3), and OSCEs (Year 2-3). Odds ratios with 95% confidence intervals were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university Grade Point Average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent). Similar analyses were conducted for first-generation university students., Results: Compared with Dutch students, the three non-Western ethnic minority groups underperformed in the CPSTs, the language test and the OSCEs. Findings on the end-of-block and writing skills tests, and results for Western minority students were less consistent. Age, gender, pu-GPA and additional socio-demographic variables could explain the ethnicity-related differences in theoretical examinations, but not in language, clinical and writing skills examinations. First-generation university students only underperformed in the language test., Conclusion: Ethnic minority students underperform in pre-clinical training, but there are differences both across ethnic subgroups and between different types of examinations. In designing assessment programs care should be taken to avoid unintended effects of certain types of examinations for certain groups of students.

Context: Despite evidence for the predictive value of both pre-admission characteristics and past performance at medical school, their relative contribution to predicting medical school performance has not been thoroughly investigated., Objectives: This study was designed to determine the relative importance of pre-admission characteristics and past performance in medical school in predicting student performance in pre-clinical and clinical training., Methods: This longitudinal prospective study followed six cohorts of students admitted to a Dutch, 6-year, undergraduate medical course during 2002-2007 (n = 2357). Four prediction models were developed using multivariate logistic regression analysis. Main outcome measures were 'Year 1 course completion within 1 year' (models 1a, 1b), 'Pre-clinical course completion within 4 years' (model 2) and 'Achievement of at least three of five clerkship grades of ≥ 8.0' (model 3). Pre-admission characteristics (models 1a, 1b, 2, 3) and past performance at medical school (models 1b, 2, 3) were included as predictor variables., Results: In model 1a - including pre-admission characteristics only - the strongest predictor for Year 1 course completion was pre-university grade point average (GPA). Success factors were 'selected by admission testing' and 'age > 21 years'; risk factors were 'Surinamese/Antillean background', 'foreign pre-university degree', 'doctor parent' and male gender. In model 1b, number of attempts and GPA at 4 months were the strongest predictors for Year 1 course completion, and male gender remained a risk factor. Year 1 GPA was the strongest predictor for pre-clinical course completion, whereas being male or aged 19-21 years were risk factors. Pre-clinical course GPA positively predicted clinical performance, whereas being non-Dutch or a first-generation university student were important risk factors for lower clinical grades. Nagelkerke's R(2) ranged from 0.16 to 0.62., Conclusions: This study not only confirms the importance of past performance as a predictor of future performance in pre-clinical training, but also reveals the importance of a student's background as a predictor in clinical training. These findings have important practical implications for selection and support during medical school., (© 2015 John Wiley & Sons Ltd.)

Context: Medical schools in Western societies seek measures to increase the diversity of their student bodies with respect to ethnicity and social background. Currently, little is known about the effects of different selection procedures on student diversity., Objectives: This prospective cohort study aimed to determine performance differences between traditional and non-traditional (i.e. ethnic minority and first-generation university candidates) medical school applicants in academic and non-academic selection criteria., Methods: Applicants in 2013 (n = 703) were assessed on academic and non-academic selection criteria. They also completed a questionnaire on ethnicity and social background. Main outcome measures were 'not selected' (i.e. failure on any criteria), 'failure on academic criteria' and 'failure on non-academic criteria'. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch applicants, adjusted for age, gender, additional socio-demographic variables (first-generation immigrant, first-generation university applicant, first language, medical doctor as parent) and pre-university grade point average (pu-GPA). Similar analyses were performed for first-generation university applicants., Results: Compared with Dutch applicants, Surinamese/Antillean applicants underperformed in the selection procedure (failure rate: 78% versus 57%; adjusted OR 2.52, 95% CI 1.07-5.94), in particular on academic criteria (failure rate: 66% versus 34%; adjusted OR 3.00, 95% CI 1.41-6.41). The higher failure rate of first-generation university applicants on academic criteria (50% versus 37%; unadjusted OR 1.66, 95% CI 1.18-2.33) was partly explained by additional socio-demographic variables and pu-GPA. The outcome measure 'failure on non-academic criteria' showed no significant differences among the ethnic or social subgroups., Conclusions: The absence of differences on non-academic criteria was promising with reference to increasing social and ethnic diversity; however, the possibility that self-selection instigated by the selection procedure is stronger in applicants from non-traditional backgrounds cannot be ruled out. Further research should also focus on why cognitive tests might favour traditional applicants., (© 2014 John Wiley & Sons Ltd.)

Objective: Each year over 1.5 million health care professionals attend emergency care courses. Despite high stakes for patients and extensive resources involved, little evidence exists on the quality of assessment. The aim of this study was to evaluate the validity and reliability of commonly used formats in assessing emergency care skills., Methods: Residents were assessed at the end of a 2-week emergency course; a subgroup was videotaped. Psychometric analyses were conducted to assess the validity and inter-rater reliability of the assessment instrument, which included a checklist, a 9-item competency scale and a global performance scale., Results: A group of 144 residents and 12 raters participated in the study; 22 residents were videotaped and re-assessed by 8 raters. The checklists showed limited validity and poor inter-rater reliability for the dimensions "correct" and "timely" (ICC = .30 and.39 resp.). The competency scale had good construct validity, consisting of a clinical and a communication subscale. The internal consistency of the (sub)scales was high (α = .93/.91/.86). The inter-rater reliability was moderate for the clinical competency subscale (.49) and the global performance scale (.50), but poor for the communication subscale (.27). A generalizability study showed that for a reliable assessment 5-13 raters are needed when using checklists, and four when using the clinical competency scale or the global performance scale., Conclusions: This study shows poor validity and reliability for assessing emergency skills with checklists but good validity and moderate reliability with clinical competency or global performance scales. Involving more raters can improve the reliability substantially. Recommendations are made to improve this high stakes skill assessment.

Background: A two-step selection procedure, consisting of a non-academic and an academic step, was recently shown to select students with a 2.6 times lower risk of early dropout and a higher clerkship Grade Point Average (GPA) than lottery-admitted controls., Aim: To determine the relative contribution of the non-academic and academic steps to differences found in student performance., Method: Lottery-admitted students (n = 653) and three groups of selection procedure participants were compared on early dropout rate and clerkship GPA: (1) all participants (n = 1676), (2) participants who passed step 1, and (3) participants who passed step 2., Results: Selection procedure participation resulted in a 4.4% lower dropout rate than lottery admission and this difference increased to 5.2% after step 1 and to 8.7% after step 2. Clerkship GPA was significantly higher for participants who passed step 1 than for their lottery-admitted controls. This difference remained significant after the rejection of students on academic criteria in step 2., Conclusion: The lower dropout rate of selected students is related to both self-selection of participants before the start of the selection procedure and the academic part of the selection procedure. The higher clerkship GPA of selected students is almost exclusively related to the non-academic selection criteria.

Background: There is a need for outcome-based studies on strategies for supporting at-risk medical students that use long-term follow-up and contemporaneous controls., Aim: To measure the effect of a short integrated study skills programme (SSP) on the study progress of at-risk medical students., Methods: First-year students identified as at-risk of academic failure at 7 months after enrolment were invited to participate in the randomised controlled trial. Participants were randomly assigned to the SSP group or to a control group receiving standard academic support. Effects of SSP were measured on the short (passed first exam after intervention), medium (obtained enough credits to proceed to second year) and long term (completed first-year curriculum within 2 years)., Results: SSP participants (n=43) more often passed the first exam after the intervention than controls (n=41; 30% versus 12%; X2(1)=4.06, p<0.005, effect size=0.22), in particular those who had previously passed at least one exam. No medium or long-term effect was found. Participants who had attended four or five SSP sessions outperformed those who had attended fewer sessions on all outcome measures., Conclusion: A short, integrated SSP benefited some, but not all students. Our advice is to focus support efforts on at-risk students who have demonstrated commitment and academic potential.

Context: Medical schools wish to better understand why some students excel academically and others have difficulty in passing medical courses. Components of self-regulated learning (SRL), such as motivational beliefs and learning strategies, as well as participation in scheduled learning activities, have been found to relate to student performance. Although participation may be a form of SRL, little is known about the relationships among motivational beliefs, learning strategies, participation and medical school performance., Objectives: This study aimed to test and cross-validate a hypothesised model of relationships among motivational beliefs (value and self-efficacy), learning strategies (deep learning and resource management), participation (lecture attendance, skills training attendance and completion of optional study assignments) and Year 1 performance at medical school., Methods: Year 1 medical students in the cohorts of 2008 (n = 303) and 2009 (n = 369) completed a questionnaire on motivational beliefs and learning strategies (sourced from the Motivated Strategies for Learning Questionnaire) and participation. Year 1 performance was operationalised as students' average Year 1 course examination grades. Structural equation modelling was used to analyse the data., Results: Participation and self-efficacy beliefs were positively associated with Year 1 performance (β = 0.78 and β = 0.19, respectively). Deep learning strategies were negatively associated with Year 1 performance (β =- 0.31), but positively related to resource management strategies (β = 0.77), which, in turn, were positively related to participation (β = 0.79). Value beliefs were positively related to deep learning strategies only (β = 0.71). The overall structural model for the 2008 cohort accounted for 47% of the variance in Year 1 grade point average and was cross-validated in the 2009 cohort., Conclusions: This study suggests that participation mediates the relationships between motivation and learning strategies, and medical school performance. However, participation and self-efficacy beliefs also made unique contributions towards performance. Encouraging participation and strengthening self-efficacy may help to enhance medical student performance., (© Blackwell Publishing Ltd 2012.)

Context: Research from numerous medical schools has shown that students from ethnic minorities underperform compared with those from the ethnic majority. However, little is known about why this underperformance occurs and whether there are performance differences among ethnic minority groups., Objectives: This study aimed to investigate underperformance across ethnic minority groups in undergraduate pre-clinical and clinical training., Methods: A longitudinal prospective cohort study of progress on a 6-year undergraduate medical course was conducted in a Dutch medical school. Participants included 1661 Dutch and 696 non-Dutch students who entered the course over a consecutive 6-year period (2002-2007). Main outcome measures were performance in Year 1 and in the pre-clinical and clinical courses. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch students, adjusted for age, gender, pre-university grade point average (pu-GPA), additional socio-demographic variables (first-generation immigrant, urban background, first-generation university student, first language, medical doctor as parent) and previous performance at medical school., Results: Compared with Dutch students, Surinamese and Antillean students specifically underperformed in the Year 1 course (pass rate: 37% versus 64%; adjusted OR 0.40, 95% CI 0.27-0.60) and the pre-clinical course (pass rate: 19% versus 41%; adjusted OR 0.57, 95% CI 0.35-0.93). On the clinical course all non-Dutch subgroups were less likely than Dutch students to receive a grade of ≥ 8.0 (at least three of five grades: 54-77% versus 88%; adjusted ORs: 0.17-0.45)., Conclusions: Strong ethnic disparities exist in medical school performance even after adjusting for age, gender, pu-GPA and socio-demographic variables. More subjective grading cannot be ruled out as a cause of lower grades in clinical training, but other possible explanations should be studied further to mitigate the disparities., (© Blackwell Publishing Ltd 2012.)

Context: Medical students often fail to finish medical school within the designated time. An academic dismissal (AD) policy aims to enforce satisfactory progress and to enable early identification and timely support or referral of struggling students. In this study, we assessed whether the implementation of an AD policy improved study progress in the first 2 years of medical school. Additionally, we analysed its effect on the help-seeking behaviour of struggling students., Methods: We compared two AD cohorts (entering in 2005 and 2006, respectively) and two non-AD cohorts (entering in 2003 and 2004, respectively) on dropout rates, Year 1 curriculum completion rates and the percentage of students with an optimal study rate (i.e. all modules completed) at 1 and 2 years after enrolment. We also measured the effect on study progress of attending the support meetings offered., Results: The AD (n = 809) and non-AD cohorts (n = 809) did not differ significantly in dropout rate at 5 months, in Year 1 completion rate at 2 years and in the percentage of optimally performing students at 1 year after enrolment. At 2 years after enrolment, more students from the AD cohorts had left and more non-AD students demonstrated optimal performance, but effect sizes (ESs) for these differences were small. Voluntary support at 4 months was attended by AD students more often than by non-AD students (68.9% versus 39.8%; χ(2) ((1)) = 43.95, p < 0.001, ES = 0.29). The AD students who attended the support meetings completed the Year 1 curriculum more often than those who did not (73.4% versus 52.5%; χ(2) ((1)) = 10.92, p < 0.001, ES = 0.20). Attending the obligatory support meeting at 7 months had a similar effect (70.5% versus 33.3%; χ(2) ((1)) = 13.60, p < 0.001, ES = 0.23)., Conclusions: The presence of an AD policy did not lead to earlier dropout, higher completion rates or an improved study rate during the first 2 years at medical school. However, uptake of the support offered increased to almost 70%. Although support participants finished the Year 1 curriculum more often than non-participants, the current support system was not sufficient to improve overall study progress., (© Blackwell Publishing Ltd 2011.)