A Braun

A Milburn

B Griffin

EH Schein

JA Chatman

JA Cleland

K Mattick

ME Young

Medical Schools Council

NM Ashkanasy

P Baughan

P Craig

P Trowler

PR Trowler

S Curtis

S Razack

S Saha

SJ Ball

V Bamber

Perspectives on Medical Education

English

PubMed

Kirsty Alexander

Jennifer Cleland

Sandra Nicholson

Crossref

Let us not neglect the impact of organizational culture on increasing diversity within medical schools

Alexander, Kirsty

Cleland, Jennifer

Nicholson, Sandra

Aberdeen University Research

COMMENTARYDOI 10.1007/s40037-017-0342-4Perspect Med Educ (2017) 6:65–67Let us not neglect the impact of organizational culture on increasingdiversity within medical schoolsKirsty Alexander1 · Jennifer Cleland1 · Sandra Nicholson2Published online: 28 February 2017© The Author(s) 2017. This article is available at SpringerLink with Open Access.In this issue, Young et al. present a six-point frameworkfor pipeline and program development, intended to increasediversity in Canadian medical schools [1]. Using a frame-work of knowledge translation, the authors emphasize thekey role of collecting and monitoring longitudinal diver-sity-related data in designing, implementing and evaluatingdiversity-related initiatives. Young et al. argue the use ofsuch data will not only improve best practice, but will alsohelp build more tailored structures for lasting change.We wholeheartedly agree that such data are essential.However, Young et al.’s focus on processes, new initiativesand structural change positions the article at the level of or-ganizational and systems-level change. This is potentiallyproblematic as, while systems-level changes may be an im-portant initial step towards reducing functional barriers (to,in this case, increasing diversity within medicine), unlessthese barriers are also addressed at a cultural level, it isunlikely change will be effective, lasting or genuine [2, 3].Institutional culture is loosely understood to be theshared assumptions, meanings, beliefs, understandings andideas held within an organization, school or team – witha focus on values and judgements, rather than proceduresand practices [4]. In established institutions, culture oftenerrs towards stability and the status quo, largely allowingpeople to stay within their comfort zones and use estab-All three authors have a keen research and practical interest inselection and widening access to medicine. Kirsty Alexanderkirsty.alexander@abdn.ac.uk1 Institute of Education in Medical and Dental Sciences,University of Aberdeen, Aberdeen, UK2 Centre for Medical Education, Barts and The London Schoolof Medicine and Dentistry, London, UKlished approaches rather than challenging these with inno-vation and growth [5]. Furthermore, medicine, and selectioninto medical school, are influenced by a pervasive culturebased on meritocracy, where the prior academic achieve-ments of applicants may be over-emphasized. Therefore,although an admissions system may be perceived to beeffective by those in the institution, (for example, becauseit processes large numbers of applications efficiently oradmits students who historically have low dropout rates), itmay not be conducive to achieving ‘newer’ goals, such asthose of increased diversity.For example, and drawing on data from medical schoolsrepresented in the Young et al. study, Razack and col-leagues [6–8] identified a potential conflict between medicalschools’ definition of excellence and a culture that wouldpermit goals for increased diversity (referred to here aswidening access) to be met. As a group, medical schools’discourses reflected that they valued ‘excellence in schol-arship’ above other, potentially broader and more inclu-sive, notions of excellence [8]. Similarly, Alexander et al.’s[9] recent discourse analysis of UK medical school web-sites identified that, while the discourse of widening ac-cess for social mobility through academic meritocracy wasdominant, a counter discourse for improving the workforcethrough increased diversity was marginalized. In neitherstudy was widening access displayed as a strength, imply-ing that while institutions may, at one level, acknowledgethe need to widen access, and claim to put systems in placewhich support this, these systems may not be accompaniedby a cultural shift towards truly embracing the value ofdiversity in medicine. Admissions practices, policies andtheir institutional interpretations may instead act as ‘filters’[10] to intercept, moderate and even halt the effective im-plementation of widening access.66 K. Alexander et al.While acknowledgement of the need for cultural changemay be especially important at a leadership level, as lead-ers exercise influence over their organization’s culture [11],at the same time, ‘top-down’ change is more likely to besustained if it is embraced locally [2, 3]. This is clear inmedical admissions. For example, Cleland et al.’s study[12] revealed that the aims of key stakeholders – the gov-ernment policy makers and those who had to enact direc-tives, the admissions deans – were often not in alignmentwith regard to widening access goals. Indeed, their datahinted that the political goal of widening access and med-ical education’s goal of producing the best doctors mayconflict. Moreover, these and other data [13] indicate thatthose medical schools that embrace widening access at anorganizational culture level may be more attractive to appli-cants from demographic groups currently underrepresentedin medicine.The aims and values of Young et al.’s proposed frame-work [1] need to align with the aims and values of thosewho would be working with it, or the framework’s impactis likely to be diluted or superficially incorporated for ac-countability purposes [12, 14–16]. However, only in theirvery last case study do Young and colleagues really stressthe importance of developing markers and data collectionprocesses in partnership with stakeholders. Leaving this asa later step implies to us an assumption that the stakeholderswill share their views about increasing diversity. This maynot be the case (see earlier) and it is much more likely thatany framework will be implemented effectively if the viewsof stakeholders are sought very early on, to inform the pro-cesses of development, implementation and evaluation ofchange [17, 18].Our final point is that, although cultural change in re-gard to medical admissions and increasing diversity maybe notoriously difficult to enact, it is far from impossible.For example, in many countries medicine has become muchmore inclusive with regards to gender and some minorityethnic groups – but continues to lag behind in terms of in-creasing diversity on the grounds of socio-economic class[19–22]. It seems clear from patterns of success in increas-ing diversity that medical admissions are linked to widersocietal issues. This is acknowledged by Young et al., whorefer to the participation of Indigenous communities withinmedical education in the Canadian context. These wider is-sues must be taken into account when considering wideningaccess and associated initiatives in any setting. However,it is also important to acknowledge very local contextualconsiderations. Each medical school has its own historical,social and local issues shaping the institutional culture andissues surrounding diversity and inclusion. Medical schoolA may embrace widening access while medical school B, inthe same city, may be less overtly engaged, and the reasonsfor these differences are probably associated with medicalschool culture.We call for more research exploring the influence ofthe particular cultural contexts: those of the wider socio-cultural, institutional and historical settings, and the com-plexities of the universities and medical schools withinwhich medical admissions are situated and enacted. Theseissues may be effectively considered by a meso-level ap-proach to promote and evaluate the necessary culturalchange involved in establishing successful widening accessprogrammes and policies [10, 12, 23].In conclusion, coherent, evidence-informed frameworkswith robust longitudinal data which allow us to evaluateprogress are important to assessing the impact of wideningaccess systems-level changes. However, unless there is anaccompanying change in culture, we may be implement-ing superficial systems changes over a cultural status quothat is not conducive to achieving the goals of wideningaccess. Only through a better understanding of the cultureswithin medical institutions that hamper increased diversity,can we target our efforts to implement lasting change toinstitutional systems and practices.Open Access This article is distributed under the terms of theCreative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricteduse, distribution, and reproduction in any medium, provided you giveappropriate credit to the original author(s) and the source, provide alink to the Creative Commons license, and indicate if changes weremade.References1. Young ME, Thomas A, Varpio L, et al. Facilitating admissionsof diverse students: a six-point, evidence-informed framework forpipeline and program development. Perspect Med Educ. 2017;6.doi:10.1007/s40037-017-0341-5.2. Bamber V, Trowler P, Saunders M. Enhancing learning, teaching,assessment and curriculum in higher education: theory, cases, prac-tices. New York: McGraw-Hill; 2009.3. Baughan P. Culture and culture change in a higher education con-text: what works and what doesn’t? Learn City J. 2012;2:19–28.4. Ashkanasy NM, Wilderom CPM, Peterson MF. Introduction to thehandbook of organizational culture and climate. In: Ashkanasy NM,Wilderom CPM, Peterson MF, editors. The handbook of organiza-tional culture and climate. Thousand Oaks: SAGE; 2010. pp. 3–10.5. Chatman JA, Jehn KA. Assessing the relationship between indus-try characteristics and organizational culture: how different can yoube? Acad Manag J. 1994;37:522–53.6. Razack S, Lessard D, Hodges BD, Maguire MH, Steinert Y. Themore it changes; the more it remains the same: a foucauldian anal-ysis of Canadian policy documents relevant to student selection formedical school. Adv Health Sci Educ. 2014;19:161–81.7. Razack S, Maguire M, Hodges B, Steinert Y. What might we besaying to potential applicants to medical school? Discourses of ex-cellence, equity, and diversity on the web sites of Canada’s 17 med-ical schools. Acad Med. 2012;87:1323–9.Let us not neglect the impact of organizational culture on increasing diversity within medical schools 678. Razack S, Hodges B, Steinert Y, Maguire M. Seeking inclusion inan exclusive process: discourses of medical school student selec-tion. Med Educ. 2015;49:36–47.9. Alexander K, Fahey Palma T, Nicholson S, Cleland J. Why notyou? Discourses of widening access on UK medical school web-sites. Med Educ. 2017. doi:10.1111/medu.13264 [Epub ahead ofprint].10. Trowler PR. A sociology of teaching, learning and enhancement :improving practices in higher education. Rev Sociol. 2005;76:13–32.11. Schein EH. Organizational culture and leadership. San Francisco:Jossey-Bass; 2004.12. Cleland JA, Nicholson S, Kelly N, Moffat M. Taking context seri-ously: explaining widening access policy enactments in UK medi-cal schools. Med Educ. 2015;49:25–35.13. Curtis S, Blundell C, Platz C, Turner L. Successfully widening ac-cess to medicine. Part 1: recruitment and admissions. J R Soc Med.2014;107:342–6.14. Ball SJ. Education reform: a critical and post-structural approach.Buckingham: Open University Press; 1994.15. Braun A, Ball SJ, Maguire M, Hoskins K. Taking context seriously:towards explaining policy enactments in the secondary school. Dis-course Stud Cult Polit Educ. 2011;32:585–96.16. Braun A, Maguire M, Ball SJ. Policy enactments in the UK sec-ondary school: examining policy, practice and school positioning.J Educ Policy. 2010;25(4):547–60.17. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.Developing and evaluating complex interventions: the new MedicalResearch Council guidance. BMJ. 2008; doi:10.1136/bmj.a1655.18. Mattick K, Barnes R, Dieppe P. Medical education: a particu-larly complex intervention to research. Adv Health Sci Educ.2013;18:769–78.19. Milburn A. Fair access to professional careers. The independent re-viewer on social mobility and child poverty. 2012.20. Medical Schools Council. Selecting for excellence: final report.London: Medical Schools Council; 2014.21. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racialand ethnic composition and diversity-related outcomes in US med-ical schools. JAMA. 2008;300:1135–45.22. Griffin B, Hu W. The interaction of socio-economic status and gen-der in widening participation in medicine. Med Educ. 2015;49:103–13.23. Trowler P. Cultures and Change in Higher Education: Theories andPractices (Universities into the 21st Century). New York: PalgraveMacmillan; 2008.Kirsty Alexander is a PhD candidate in the Institute of Educationin Medical and Dental Sciences, University of Aberdeen, UK. Her re-search interests are in widening access and increasing diversity in med-ical schools.Jennifer Cleland is John Simpson Chair of Medical Education Re-search in the same institution.Sandra Nicholson is based in Barts and The London School ofMedicine and Dentistry, Queen Mary University of London, UK.

University of Dundee Online Publications

Alexander, K

Cleland, J

Nicholson, S

Queen Mary Research Online

COMMENTARYDOI 10.1007/s40037-017-0342-4Perspect Med Educ (2017) 6:65–67Let us not neglect the impact of organizational culture on increasingdiversity within medical schoolsKirsty Alexander1 · Jennifer Cleland1 · Sandra Nicholson2Published online: 28 February 2017© The Author(s) 2017. This article is available at SpringerLink with Open Access.In this issue, Young et al. present a six-point frameworkfor pipeline and program development, intended to increasediversity in Canadian medical schools [1]. Using a frame-work of knowledge translation, the authors emphasize thekey role of collecting and monitoring longitudinal diver-sity-related data in designing, implementing and evaluatingdiversity-related initiatives. Young et al. argue the use ofsuch data will not only improve best practice, but will alsohelp build more tailored structures for lasting change.We wholeheartedly agree that such data are essential.However, Young et al.’s focus on processes, new initiativesand structural change positions the article at the level of or-ganizational and systems-level change. This is potentiallyproblematic as, while systems-level changes may be an im-portant initial step towards reducing functional barriers (to,in this case, increasing diversity within medicine), unlessthese barriers are also addressed at a cultural level, it isunlikely change will be effective, lasting or genuine [2, 3].Institutional culture is loosely understood to be theshared assumptions, meanings, beliefs, understandings andideas held within an organization, school or team – witha focus on values and judgements, rather than proceduresand practices [4]. In established institutions, culture oftenerrs towards stability and the status quo, largely allowingpeople to stay within their comfort zones and use estab-All three authors have a keen research and practical interest inselection and widening access to medicine. Kirsty Alexanderkirsty.alexander@abdn.ac.uk1 Institute of Education in Medical and Dental Sciences,University of Aberdeen, Aberdeen, UK2 Centre for Medical Education, Barts and The London Schoolof Medicine and Dentistry, London, UKlished approaches rather than challenging these with inno-vation and growth [5]. Furthermore, medicine, and selectioninto medical school, are influenced by a pervasive culturebased on meritocracy, where the prior academic achieve-ments of applicants may be over-emphasized. Therefore,although an admissions system may be perceived to beeffective by those in the institution, (for example, becauseit processes large numbers of applications efficiently oradmits students who historically have low dropout rates), itmay not be conducive to achieving ‘newer’ goals, such asthose of increased diversity.For example, and drawing on data from medical schoolsrepresented in the Young et al. study, Razack and col-leagues [6–8] identified a potential conflict between medicalschools’ definition of excellence and a culture that wouldpermit goals for increased diversity (referred to here aswidening access) to be met. As a group, medical schools’discourses reflected that they valued ‘excellence in schol-arship’ above other, potentially broader and more inclu-sive, notions of excellence [8]. Similarly, Alexander et al.’s[9] recent discourse analysis of UK medical school web-sites identified that, while the discourse of widening ac-cess for social mobility through academic meritocracy wasdominant, a counter discourse for improving the workforcethrough increased diversity was marginalized. In neitherstudy was widening access displayed as a strength, imply-ing that while institutions may, at one level, acknowledgethe need to widen access, and claim to put systems in placewhich support this, these systems may not be accompaniedby a cultural shift towards truly embracing the value ofdiversity in medicine. Admissions practices, policies andtheir institutional interpretations may instead act as ‘filters’[10] to intercept, moderate and even halt the effective im-plementation of widening access.66 K. Alexander et al.While acknowledgement of the need for cultural changemay be especially important at a leadership level, as lead-ers exercise influence over their organization’s culture [11],at the same time, ‘top-down’ change is more likely to besustained if it is embraced locally [2, 3]. This is clear inmedical admissions. For example, Cleland et al.’s study[12] revealed that the aims of key stakeholders – the gov-ernment policy makers and those who had to enact direc-tives, the admissions deans – were often not in alignmentwith regard to widening access goals. Indeed, their datahinted that the political goal of widening access and med-ical education’s goal of producing the best doctors mayconflict. Moreover, these and other data [13] indicate thatthose medical schools that embrace widening access at anorganizational culture level may be more attractive to appli-cants from demographic groups currently underrepresentedin medicine.The aims and values of Young et al.’s proposed frame-work [1] need to align with the aims and values of thosewho would be working with it, or the framework’s impactis likely to be diluted or superficially incorporated for ac-countability purposes [12, 14–16]. However, only in theirvery last case study do Young and colleagues really stressthe importance of developing markers and data collectionprocesses in partnership with stakeholders. Leaving this asa later step implies to us an assumption that the stakeholderswill share their views about increasing diversity. This maynot be the case (see earlier) and it is much more likely thatany framework will be implemented effectively if the viewsof stakeholders are sought very early on, to inform the pro-cesses of development, implementation and evaluation ofchange [17, 18].Our final point is that, although cultural change in re-gard to medical admissions and increasing diversity maybe notoriously difficult to enact, it is far from impossible.For example, in many countries medicine has become muchmore inclusive with regards to gender and some minorityethnic groups – but continues to lag behind in terms of in-creasing diversity on the grounds of socio-economic class[19–22]. It seems clear from patterns of success in increas-ing diversity that medical admissions are linked to widersocietal issues. This is acknowledged by Young et al., whorefer to the participation of Indigenous communities withinmedical education in the Canadian context. These wider is-sues must be taken into account when considering wideningaccess and associated initiatives in any setting. However,it is also important to acknowledge very local contextualconsiderations. Each medical school has its own historical,social and local issues shaping the institutional culture andissues surrounding diversity and inclusion. Medical schoolA may embrace widening access while medical school B, inthe same city, may be less overtly engaged, and the reasonsfor these differences are probably associated with medicalschool culture.We call for more research exploring the influence ofthe particular cultural contexts: those of the wider socio-cultural, institutional and historical settings, and the com-plexities of the universities and medical schools withinwhich medical admissions are situated and enacted. Theseissues may be effectively considered by a meso-level ap-proach to promote and evaluate the necessary culturalchange involved in establishing successful widening accessprogrammes and policies [10, 12, 23].In conclusion, coherent, evidence-informed frameworkswith robust longitudinal data which allow us to evaluateprogress are important to assessing the impact of wideningaccess systems-level changes. However, unless there is anaccompanying change in culture, we may be implement-ing superficial systems changes over a cultural status quothat is not conducive to achieving the goals of wideningaccess. Only through a better understanding of the cultureswithin medical institutions that hamper increased diversity,can we target our efforts to implement lasting change toinstitutional systems and practices.Open Access This article is distributed under the terms of theCreative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricteduse, distribution, and reproduction in any medium, provided you giveappropriate credit to the original author(s) and the source, provide alink to the Creative Commons license, and indicate if changes weremade.References1. Young ME, Thomas A, Varpio L, et al. Facilitating admissionsof diverse students: a six-point, evidence-informed framework forpipeline and program development. Perspect Med Educ. 2017;6.doi:10.1007/s40037-017-0341-5.2. Bamber V, Trowler P, Saunders M. Enhancing learning, teaching,assessment and curriculum in higher education: theory, cases, prac-tices. New York: McGraw-Hill; 2009.3. Baughan P. Culture and culture change in a higher education con-text: what works and what doesn’t? Learn City J. 2012;2:19–28.4. Ashkanasy NM, Wilderom CPM, Peterson MF. Introduction to thehandbook of organizational culture and climate. In: Ashkanasy NM,Wilderom CPM, Peterson MF, editors. The handbook of organiza-tional culture and climate. Thousand Oaks: SAGE; 2010. pp. 3–10.5. Chatman JA, Jehn KA. Assessing the relationship between indus-try characteristics and organizational culture: how different can yoube? Acad Manag J. 1994;37:522–53.6. Razack S, Lessard D, Hodges BD, Maguire MH, Steinert Y. Themore it changes; the more it remains the same: a foucauldian anal-ysis of Canadian policy documents relevant to student selection formedical school. Adv Health Sci Educ. 2014;19:161–81.7. Razack S, Maguire M, Hodges B, Steinert Y. What might we besaying to potential applicants to medical school? Discourses of ex-cellence, equity, and diversity on the web sites of Canada’s 17 med-ical schools. Acad Med. 2012;87:1323–9.Let us not neglect the impact of organizational culture on increasing diversity within medical schools 678. Razack S, Hodges B, Steinert Y, Maguire M. Seeking inclusion inan exclusive process: discourses of medical school student selec-tion. Med Educ. 2015;49:36–47.9. Alexander K, Fahey Palma T, Nicholson S, Cleland J. Why notyou? Discourses of widening access on UK medical school web-sites. Med Educ. 2017. doi:10.1111/medu.13264 [Epub ahead ofprint].10. Trowler PR. A sociology of teaching, learning and enhancement :improving practices in higher education. Rev Sociol. 2005;76:13–32.11. Schein EH. Organizational culture and leadership. San Francisco:Jossey-Bass; 2004.12. Cleland JA, Nicholson S, Kelly N, Moffat M. Taking context seri-ously: explaining widening access policy enactments in UK medi-cal schools. Med Educ. 2015;49:25–35.13. Curtis S, Blundell C, Platz C, Turner L. Successfully widening ac-cess to medicine. Part 1: recruitment and admissions. J R Soc Med.2014;107:342–6.14. Ball SJ. Education reform: a critical and post-structural approach.Buckingham: Open University Press; 1994.15. Braun A, Ball SJ, Maguire M, Hoskins K. Taking context seriously:towards explaining policy enactments in the secondary school. Dis-course Stud Cult Polit Educ. 2011;32:585–96.16. Braun A, Maguire M, Ball SJ. Policy enactments in the UK sec-ondary school: examining policy, practice and school positioning.J Educ Policy. 2010;25(4):547–60.17. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.Developing and evaluating complex interventions: the new MedicalResearch Council guidance. BMJ. 2008; doi:10.1136/bmj.a1655.18. Mattick K, Barnes R, Dieppe P. Medical education: a particu-larly complex intervention to research. Adv Health Sci Educ.2013;18:769–78.19. Milburn A. Fair access to professional careers. The independent re-viewer on social mobility and child poverty. 2012.20. Medical Schools Council. Selecting for excellence: final report.London: Medical Schools Council; 2014.21. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racialand ethnic composition and diversity-related outcomes in US med-ical schools. JAMA. 2008;300:1135–45.22. Griffin B, Hu W. The interaction of socio-economic status and gen-der in widening participation inmedicine. Med Educ. 2015;49:103–13.23. Trowler P. Cultures and Change in Higher Education: Theories andPractices (Universities into the 21st Century). New York: PalgraveMacmillan; 2008.Kirsty Alexander is a PhD candidate in the Institute of Educationin Medical and Dental Sciences, University of Aberdeen, UK. Her re-search interests are in widening access and increasing diversity in med-ical schools.Jennifer Cleland is John Simpson Chair of Medical Education Re-search in the same institution.Sandra Nicholson is based in Barts and The London School ofMedicine and Dentistry, Queen Mary University of London, UK.

Let us not neglect the impact of organizational culture on increasing diversity within medical schools.

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Let us not neglect the impact of organizational culture on increasing diversity within medical schools.

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