Widening access to medical school in Australia: a realist evaluation

Introduction: While medical school selection research has largely focused on the validity of tools and processes, less attention has been paid to the quality and impact of widening access (WA) pathways. Existing studies are often limited in scope, focusing on single institutions or interventions. This study aimed to develop transferable insights into WA selection practices through a realist evaluation across four Australian medical schools.

Methods: Building on a prior realist review, we employed the RAMESES II protocol to explore how contextual factors and mechanisms interact to influence WA outcomes through four case studies. Data collection included institutional document and website reviews, semistructured interviews and focus groups (41 staff and 17 students). The evaluation framework examined context (diversity within sociocultural settings), interventions (targeted pathways and adjusted selection scores), mechanisms (institutional, dispositional and situational) and outcomes (applicant diversity, selection success). Retroductive context–intervention-mechanism–outcome (CIMO) analysis clarified WA programme theory.

Results: Two key interventions were successful across all sites: (1) targeted pathways with selection score adjustments for under-represented groups (e.g., Indigenous, rural and low socio-economic backgrounds) and (2) sustained partnerships with these communities to raise awareness of medicine as a viable career. These partnerships aimed to enhance applicants' dispositions and readiness for selection. However, structural changes within institutions posed significant risks to the sustainability of WA. The resulting programme theory identified five mechanisms underpinning effective WA: visionary leadership, Indigenous cultural safety, longitudinal relational engagement, tailored applicant support and preparation for selection processes.

Discussion: This realist evaluation highlights how institutional commitment, shaped by federal policy and accreditation standards, has driven demographic shifts, particularly in rural and Indigenous representation, over a 10- to12-year period; however, the scope of WA remains narrow. We argue for a national, coordinated approach to WA in medical education, underpinned by long-term investment, robust evaluation and a broader conceptualisation of equity in access. WA must be embedded as a core institutional commitment rather than a peripheral initiative.