What the hell is water? Changing medical education's ideology through validity

In 2005, American novelist David Foster Wallace gave a commencement speech to the graduating class at Kenyon College in the United States. He opened the speech with a parable about two fish:

Of course, the wisdom in this story is that the ideologies that constitute our realities are often transparent to us, but may not be to others. Assumptions that are baked into our worldviews can keep us from questioning what may be noticeable or unusual to outsiders or novices.

In this issue of Medical Education, Coyle et al challenge us to examine the waters in which we swim.² They note that efforts to improve widening participation and access to medicine for people from under-privileged or minoritised backgrounds are at tension with medical education's preoccupation with academic excellence as a key metric for applicant selection. The authors poignantly write, ‘We suggest that it is time for medical schools to acknowledge that some of the drivers for ever higher academic thresholds for entry to medicine are artifacts of managing the number of applicants rather than anything more noble’. Such a bold call should rouse medical education to scrutinise the entrenched use of academic excellence as a selection standard by re-examining the rationale for doing so.

Academic performance has ruled medical education selection for decades, embedding itself as an ideological norm. We no longer question why it is used in applicant selection. It has become part of medical education's ideology, often passing ‘unseen as normal or as factual’³ like water to our parabolic fish. However, the suboptimal diversity, equity and inclusion of medical education's assessment and selection practices are being increasingly recognised as a wicked problem,⁴ leading to more frequent scrutiny of sacred (or unseen) ideologies. In response, we believe medical education should consider removing academic excellence as the gatekeeping metric to our profession.

Ostensibly, the most important stakeholders of applicant selection are learners and patients. For learners, selection represents the culmination of years of study, service and research. Selection presents a high-stakes branchpoint that dictates much of learners' future career. For patients, selection represents an accountability mechanism to ensure that future physicians are prepared for the rigours of medical training and capable of providing high-quality care. We should, then, question if relying on academic excellence serves these groups. Coyle et al's work suggests that academic excellence presents a roadblock for learners from under-privileged or minoritised backgrounds who are unfairly disadvantaged due to systematic bias. This unfairness certainly harms such learners, indicating that academic excellence is not beneficial to one of our key stakeholder groups. Patients are also harmed. Multiple studies have shown that perceived care quality and improved clinical outcomes are associated with patient–physician racial concordance for minoritised populations.^5-7 Therefore, admitting diverse training cohorts best positions the health professions to serve diverse patient populations. While the reduction of physician workforce diversity due to biased selection metrics (such as academic excellence) is just one factor contributing to widespread racial and ethnic healthcare disparities,⁸ it is a factor that is within medical education's sphere of control. As Varpio wrote, ‘Fortunately, ideology is maintained by our decisions and actions; therefore, we can change our decisions and thereby modify the ideology to work for us, not against us’. In other words, we choose the waters in which we swim, and we have agency to change.

One way to modify our ideology is to consider diversity and equity as part of validity arguments for selection decisions. Medical education has largely adopted that validity is not a property of a specific instrument or tool, but rather an argument with supporting evidence that a given decision, interpretation or use of data is justifiable or defensible.^{9, 10} One type of evidence that is often overlooked¹¹ but critical to validity arguments relates to the consequences of decisions. Consequences evidence ‘looks at the impact, beneficial or harmful and intended or unintended, of assessment’.¹² Coyle et al show how academic excellence works against diversity and equity policies and initiatives. If the inequitable treatment of under-privileged and minoritised learners or the negative downstream consequences to patients are unacceptable (as they should be), then selection decisions that centre on academic excellence are not valid. Hauer et al have previously argued that diversity and equity considerations should be included in medical education assessment validity arguments.¹³ We agree and believe that the same considerations should be extended selection decisions.

To be clear, we are not arguing that learners from under-privileged or minoritised backgrounds are not excellent. Rather, we believe that the societal and systemic inequities and biased assessment strategies make academic performance an indefensible metric to use as the crux of selection for physician training. Selection decisions relying primarily on academic excellence are not valid if diversity and equity become key aspects of our validity arguments. We are also not implying that toppling academic excellence is an easy task. Changing medical education's ideology can seem daunting, but we must remember that it is within our control. We are actors in this network, with agency to swim to new ideological waters that embrace selection metrics which are more beneficial for both learners and patients. But first we must ask the fraught question, ‘What the hell is water?’

Benjamin Kinnear: Conceptualization; writing—original draft preparation; writing—review and editing. Daniel J. Schumacher: Conceptualization; writing—original draft preparation; writing—review and editing.