Retention beyond representation: A call for structural inclusion in health professions education

The sense of belonging in higher education, particularly among students from historically, persistently or systematically marginalised (HPSM) groups, has increasingly been explored in the past few years.^1-3 Poitevien et al.⁴ add to this body of knowledge by highlighting the importance of belonging in medical education, rightly pointing out that diversity alone is insufficient. We assert that without structural changes, merely increasing representation risks reinforcing stereotypes, potentially leading HPSM students to struggle and fail.

Yet, one notable limitation in diversity research in health professions education is the tendency to overlook disability as a key factor in representation. This oversight reflects a bias in health professions, where disability is often ignored as a form of minority status, especially among health professionals themselves.¹ By excluding disability from discussions of underrepresentation, institutions risk neglecting the unique challenges faced by disabled students and professionals, ultimately reinforcing exclusion. This commentary expands on Poitevien et al.'s⁴ arguments, emphasising that meaningful diversity necessitates retention-focused inclusion that integrates systemic support, values unique perspectives and fosters continuous institutional transformation.

While diversity initiatives in health professions education may improve representation, they often lack the structural support that HPSM students need to thrive. Tokenistic approaches—recruiting underrepresented students without enacting structural reform—can do more harm than good by exposing HPSM students to hostile and unsafe environments steeped in exclusionary values.¹ This approach inadvertently reinforces stereotypes by setting minority students up for failure within systems that have not adapted to support them.^{1, 5} Without retention-focused support, diversity efforts may reinforce rather than dismantle perceptions that minority students are ‘unsuited’ for health professions.⁶

When HPSM students are admitted without changes to institutional standards, they often carry an undue ‘burden of proof’. Disabled students, for example, face additional pressure to conform to traditional competency standards that fail to account for diverse ways of demonstrating excellence, often suppressing parts of their identities to appear ‘professional’.^{1, 6} Similarly, Black and Hispanic health students often face pressure to suppress cultural identities to align with traditional, white professionalism standards.⁷ This constant need to prove legitimacy not only heightens stress but also detracts from HPSM students' capacities to fully engage with learning and experiencing professional growth.⁸ Revising competency standards to incorporate inclusive criteria can alleviate these pressures, fostering an environment where students succeed on their terms and experience a true sense of belonging.^{1, 5, 6}

Retention, therefore, becomes the foundation of genuine inclusion. As Poitevien et al.⁴ stress, belonging requires more than entry; it demands a commitment to sustaining students' success within the institution. Retention is intertwined with institutional legitimacy and support.^{1, 5} By prioritising retention, health professions education can surpass tokenism, affirming that minority students are valued members of the healthcare community.

Inclusion requires more than admissions policies; it involves building structures that support HPSM students throughout their education. For students from minority groups, especially those in competitive health professions educational programmes, social support and systemic accommodations are crucial for retention. While individual-based programmes like mentorship and peer networks have shown limited benefits, effective retention strategies must include institutional policies that create an inclusive and accessible learning environment, while proactively addressing barriers such as inadequate training for health education instructors and faculty on facilitating meaningful conversations about race and racism.⁹ By embedding these support systems, health institutions can shift diversity from a token gesture to a sustainable, system-wide commitment to inclusion.^{1, 5-7, 9}

Some types of knowledge are privileged in health professions, and this often silences perspectives of students and practitioners from HPSM groups. The injustice caused by excluding certain knowledge is known as epistemic injustice.¹⁰ Epistemic injustice refers to the wrong done to someone in their capacity as a knower. Due to unequal epistemic power relations, such as in academia or in the health professions, certain groups (professors, senior practitioners or practitioners from professions who hold more power or those coming from dominant Western groups, e.g. non-disabled, white male settlers) have greater power to determine what constitutes valuable knowledge and whose knowledge is warranted. The importance of epistemic inclusion—recognising and integrating the lived experiences of HPSM students and professionals—cannot be understated. HPSM health students and practitioners possess invaluable insights regarding client care through their lived experiences, a perspective that is frequently undervalued within health professions education frameworks.^{6, 11} Inclusion should transcend representation, integrating diverse experiences into health professions curricula to enhance empathy and client-centred care.¹¹ This shift would enrich health professions education, ensuring it respect, valuing knowledge within diverse communities and advancing epistemic justice by centering knowledge of HPSM students and practitioners.¹² Epistemic justice will not only foster a sense of belonging among HPSM students and practitioners but will also improve the care we provide to those whose mainstream epistemic resources are too often inadequate.¹³

Achieving true inclusion in health professions education requires moving beyond performative diversity. The studies discussed here underscore the necessity of fundamental shifts, structural supports, inclusive standards and a deep appreciation for diverse perspectives to foster retention and belonging. Health professions education and practice institutions must adopt a retention-centred approach that values each student's journey, nurtures their success and enriches healthcare services with a workforce that reflects and respects the diversity of their communities.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.