Advocacy Consultant Report

Crystal Chan, Jenny Lee, Ramachandiran (Varun) Sethuraman, Emily Siskos

Advocacy Consultation Report

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CONSULTANTS

Crystal Chan | chanccy@mcmaster.ca Jenny Lee | leejy7@mcmaster.ca Ramachandiran (Varun) Sethuraman | sethurr@mcmaster.ca Emily Siskos | siskosea@mcmaster.ca ACKNOWLEDGEMENTS

This research memo is written as component of The Health Advocacy Workshop for which students in the HTH SCI 4ZZ3 class consulted for The 53rd Week to advise their advocacy direction.

Our team would like to thank The 53rd Week for providing the opportunity to collaborate on this project. We extend our thanks to The 53rd Week Director of Operation Dr. Lawrence Loh, our instructors Jake Hirsch-Allen and Matthew Hughsam, our teaching assistant Suhasini Rao and our faculty consultant Dr. Lawrence Grierson for their continual support throughout the process. We appreciate their strong guidance in gaining a better understanding of our project’s advocacy goals and strategies as it relates to this project.

PROVENANCE STATEMENT

Research Memo This research memo was a collaborative effort by Crystal Can, Jenny Lee, Varun Sethuraman and Emily Sisko. Specifically, Crystal and Varun were responsible for Key Message 1 and the underlying research concerning admissions policies and process and its influence on student behavior. Jenny was the primary researcher behind Key Message 2 and Emily behind Key Message 4. Jenny and Emily collaborated on Key Message 3. Crystal and Varun were responsible for the abstract.

Emily, Varun and Jenny collaborated for the introduction, and Emily was the main voice behind the conclusion. Jenny and Crystal had undertaken a thorough examination of the peer reviewed feedback and recommended changes to the original draft. Crystal designed layout.

Key Informant Interviews Dr. Jessica Evert - Crystal, Jenny, Varun Dr. Christopher Dainton - Crystal, Jenny, Varun, Emily Dr. Johnathan Dowell - Jenny, Varun, Emily Other Consultants Dr. Lawrence Grierson - Crystal, Jenny, Varun, Emily 2

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ABSTRACT

There is a growing interest among pre-medical students to participate in short-term experiences in global health (STEGH) to aid their medical school admissions. Such a reality suggests a need for advocacy efforts towards medical school admissions committees, as their influence over pre-health populations could improve the conduct of STEGH overall. This research memo serves as a starting point for The 53rd Week to advocate for change within medical admissions boards in favour of improving the climate of STEGH.

To provide The 53rd Week with this initial framework, key

informant interviews, literature reviews and an environmental scan of published medical admissions policies in Ontario were conducted to inform the development of the following key recommendations: 1. The 53rd Week should advocate for admissions committees to move toward competency-based assessments of non-academic submissions: a. The 53rd Week should advocate for the use of external verification in assessing the quality of the autobiographical sketch activities; b. The 53rd Week should advocate for the use of CASPer and other moderated testing in lieu of traditional writing samples and essays; 2. The 53rd Week should adopt a social accountability framework in their advocacy initiatives towards admission committees; 3. The 53rd Week should advocate for admissions committees to be transparent on their stance towards STEGH activities; and 4. The 53rd Week should conduct further primary research on student perceptions of admissions committee policies and processes.

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TABLE OF CONTENTS

Abstract ………………………………………………………………………………………… 3 Introduction ...…………………………………………………………………………………. 5 Partnership with The 53rd Week ...………………………………………………….... 5 Focusing The 53rd Week’s Advocacy………………………………………………… 5 Research Methods………………………………………………………………………. 5 Key Message 1: Emphasize competency in assessment of non-academic submissions . 6 A | External Verification of Items on the Autobiographical Sketch (ABS) ……….... 6 The Ontario Medical School Application System (OMSAS) and the ABS .…… 6 ABS Structure and Effect on Student Behaviour …….……………...…………... 6 The Benefit of External Verification ……………………………………………….. 7 B | Situational testing and moderated written components ……………………….. 7 Traditional Essays and Personal Statements ……….……………………………. 7 The Benefit of Moderated Writing Samples and CASPer ………………………. 7 Key Message 2: Social accountability of admissions policies ……………….…………… 9 Importance of Social Accountability ……….……………….………………………… 9 Addressing Socioeconomic Disparity ………..…………….…………………………. 9 Key Message 3: Greater transparency on STEGH in the admissions process ………... 10 Current Published Material …………………………………………………………... 10 Implications of Non-Transparency ………………………………………………..…. 10 Increasing Transparency …………………………………………………………….... 10 Key Message 4: Further primary research on student perceptions ……………………. 12 Research Questions …………………………………………………………………… 12 Moving Forward ……………………………………………………………………….. 12 Conclusion ……………………………………………………………………………………. 13 References ……………………………………………………………………………………. 14 Appendix ………………………………………………………………………………..……. 17 4

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INTRODUCTION

Partnership with The 53rd Week We are senior undergraduate students at McMaster University* and as part of our global health advocacy workshop, we have temporarily partnered with The 53rd Week to assist them in their advocacy toward sustainable short-term experiences in global health (STEGH).

The 53rd Week is a non-profit organization striving to optimize the outcomes of short-term volunteer work abroad through advocacy, research, and innovation1. STEGH can range in quality, purpose, ethical conduct, sustainability and impact on host communities2. However, the organization recognizes that people have altruistic motives and will not be deterred by criticisms painting STEGH as self-serving voluntourism.3 Towards this end, The 53rd Week has organized their own STEGH for undergraduate students in an attempt toward sustainable global health development.4 Now, as The 53rd Week is undergoing an organizational pivot towards becoming an advocacy organization, it is imperative to know where they should direct their advocacy efforts.5 Focusing The 53rd Week’s Advocacy After gaining an understanding of the individual and systemic issues surrounding the conduct of STEGH, we aimed to specify an area for The 53rd Weeks advocacy. Three general advocacy directions include: (1) changing the mind of the individual (2) changing the programs in which these operations run, and (3) changing overall systemic context.6 Arguably, the most daunting task is changing the systemic context; however, it can be the most impactful as this can change the motivations behind the undertaking of STEGH.6 We discovered that admissions to medical school is a key incentive in the undertaking of STEGH by undergraduate students.7 For this reason, we believe that advocating to medical school’s admissions committees (AdComs) could be a strong approach to changing the conduct of pre-health undergraduate STEGH. Research Methods In our research process, we completed a cursory environmental scan of published admissions policies and processes in Ontario and a literature review of academic journals to understand medical admissions policies in relation to STEGH. We then consulted Dr. Johnathan Dowell, a medical school admissions committee member and educator at Dundee University; Dr. Christopher Dainton, a Toronto-based physician with expertise in the assessment of medical service trips, and Dr. Jessica Evert, the CEO of Child Family Health International and a co-founder of the Working Group on Global Activities of PreHealth Students (GASP)*. Once our research process was completed, we identified four key recommendations and future directions for The 53rd Week to pursue their advocacy towards medical AdComs. As AdComs have a primary responsibility to ensure quality future physicians and improvements in STEGH are ancillary benefits, our recommendations in accordance with these priorities. _______ * Refer to Appendix

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Emphasize Competency in Assessment of Non-Academic Submissions A | External Verification of Items on the Autobiographical Sketch (ABS)

The Ontario Medical School Application System (OMSAS) and the ABS Since 1995, the number of applications to Ontario medical schools has increased substantially without proportional increases in the number of seats.8 In response, AdComs are using non-academic information as further discriminatory measures to distinguish between these highly qualified applicants.9-14 Currently, the OMSAS allows applicants to list and briefly describe their experiences in an autobiographical sketch (ABS).15 Candidates can list up to 48 activities in 5 categories and must provide some requisite information in the format below: ABS Category

Requisite Information (250 characters)

Employment

Hours, Full/Part-time, Responsibilities

Volunteer Activities

Hours, Summer/Academic Year, Responsibilities

Extra-Curricular Activities (ECAs)

Hours, Summer or Academic Year, Type of Activity/Level of Performance

Awards and Accomplishments

When Received, Duration, Qualifications, Competition Involved

Research Experience

Title of Project, Type of Publication, My Role

ABS Structure and its Effect on Student Behaviour The structure of the OMSAS application may have implications on the behaviour of students applying to medical schools. With the addition of an ABS section, students may feel pressured to commit to non-academic solely to fill out a ‘wholesome’ application. KaplanTestPrepTM similarly stresses the need for ECAs for medical school admissions.16 But there may also be implicit messages in the ABS. For example, in the research experience category, a candidate must specify the type of publication and their role, but not the time spent or skills developed.15 This format may send the message that AdComs are less interested in the development of research skills than the publication of a report. For ECAs, the ABS asks applicants for their level of performance in the activity but not the value of the activity itself.15 The limited space given in the ABS seems to place emphasis on the results and prestige of non-academic

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activities, contrary to research showing that competency-based assessments are more valuable professionally.17 This incentive may encourage students to conduct STEGH, as an overseas clinical experience may be seen as an activity of high-prestige.

The Benefit of External Verification Although OMSAS requires students to provide verifiers for ABS submissions, the verifiers are applicant-selected, which may compromise integrity of their verifications.15 We realize that there is immense variability in the conduct of ECAs, and in particular STEGH, and that AdComs cannot spend their limited time performing background checks. However, if there are simple external resources which can verify ABS submissions, AdComs should take these measures when possible. External organizations, such as Medical Service Trip (www.medicalservicetrip.org) have databases which assess the quality of over 300 STEGH organizations and provide key information on the conduct of the STEGH including: team size, role of local leadership, role of students within the organization (learner or volunteer), and the length of trip.18 This type of information would provide AdComs knowledge of the skills gained through the organization, which fits into a competency-based framework of assessment.17 As medical education moves towards this type of assessment, it seems contradictory for the medical admissions to rely on outcome-based, self-reported information in the ABS.19 If The 53rd Week successfully advocates for AdComs to undertake this type of analysis, students may be encouraged to assess the ethics and competencies gained from STEGH organizations, which may positively influence the way they conduct STEGH. B | Situational Testing and Moderated Written Components

Traditional Essays and Personal Statements

In addition to the ABS, the University of Toronto (UofT) requires short supplementary essays.13 The essay questions are released months in advance and applicants can answer the questions any time before the deadline.13 Traditionally, written components (i.e. personal statements and essays) are common methods to evaluate personal experience and non-cognitive qualities to assess an applicant’s overall suitability to the training and professional practice.20 However, studies have shown that people will distort responses to fit the ideal personality of the job to which they are applying.21,22 Medical applicants are therefore inclined to make themselves seem caring, conscientious, responsible and agreeable to model themselves after a profile of the ‘ideal doctor’. Despite acknowledging that exaggerating one’s personal experiences is dishonest, students believe this practice to be such a widespread phenomenon that many consider this to be an acceptable practice.22 Therefore, the equivocal nature of written components often present challenges of ascertaining true authorship as applicants can have others provide feedback and editing23 and tensions between “genuine” and “expected” responses persist.22

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The Benefit of Moderated Writing Samples and CASPer McMaster University conducted a study to determine whether there is a difference in the quality of personal written statements if they were moderated. To score written components, an average of global ratings by three reviewers were taken. These ratings for candidate-written responses were found to non-uniformly increase with time. This may be because some students experience more pressure than others in timed situations or some students sought additional help with the unmoderated writing samples. Timed writing samples also correlated much better with candidates’ Multiple Mini Interview (MMI) scores, and since the MMI is a validated predictor of candidate clinical performance24-25 structured constraints in writing samples are more psychometrically valid.26 Consequently, the computer-based assessment for sampling personal characteristics (CASPer) is a timed, situational judgement test required for McMaster University and the University of Ottawa medical admissions.9,11 This pre-interview, online assessment is different from traditional writing sample in that it tests an applicant’s response to various ethical and difficult situations, rather than the applicant’s personal activities.27 As well, the time constraint and variability of CASPer make it difficult to plan or be coached through the responses, ascertaining a more genuine response.28 Introducing CASPer in lieu of traditional essays may also influence the motives behind students’ non-academic activities. CASPer does not provide ample space for students describe their non-academic achievements, but it would test their ethical and interpersonal competencies.27 This testing may encourage students to assess their organization’s initiatives for these same ethical competencies which may ultimately improve the quality of their STEGH. STEGH seem valuable to students as an eye-catching activity with positive associated attributes. However, if AdComs externally verify the quality of STEGH organizations and integrate CASPer and moderated, situational judgement testing, pre-med students may be motivated to ensure that their STEGH are ethical and provide them with useful competencies.

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Social accountability of admissions policies

Importance of Social Accountability The lack of socio-economic diversity within Canadian medical schools has significant impact on applicants, students and patients.29 It produces a physician workforce with a higher socioeconomic status and unrepresentative of the general population, further exacerbating inequities in access to care.29 The World Health Organization identifies social accountability as a mandate of medical schools, which should be reflected in the admissions process.30 The Future of Medical Education in Canada MD Report and Ontario Medical Students’ Association Report both include a key recommendation for Canadian Faculties of Medicine to increasingly recruit, and support students with low socioeconomic status to meet the diverse needs of the general population.29,31 The responsibility of Ontario medical schools to respond to societal needs is especially pronounced in a country where medical education is publically funded.31 Addressing Socioeconomic Disparity Addressing socioeconomic disparity in medical schools requires changes to the status quo, which can also improve the conduct of STEGH.31 Literature has demonstrated that traditional selection methods discriminate against those of lower socioeconomic status.32 For instance, autobiographical submissions are likely to disadvantage applicants from lower socio-economic groups due to disparities in access to appropriate network, opportunities and resources.33 International volunteer trips in the US including STEGH are most commonly conducted by young, white, male and highly educated individuals, making STEGH generally inaccessible and privileged opportunities.34 Despite previous and ongoing efforts by Ontario medical schools to recruit underrepresented minorities through modified admissions criteria and pipeline programs, a large socioeconomic disparity still remains.29 Thus, framing an admissions policy reform in Ontario whereby STEGH are critically examined as an equity measure may be an effective advocacy strategy for The 53rd Week.35 AdComs may have more impetus for reform if the issue of STEGH is presented as not only an ethical one, but also a matter of social accountability and inclusiveness.35 According to Dr. Dowell, AdComs would be particularly receptive to this framework if supported by research showing that undergraduate students perceive STEGH as an unfair boost in the admissions process.35

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Greater transparency on STEGH in the admissions process

Current Published Material The lack of transparency in medical school admissions policies has not garnered much discussion and investigation in US and Canada according to Dr. Jessica Evert.36 However, it is undeniable that clarity in admissions criteria deserves more attention as it can have major influences in applicant behaviours.36 STEGH were not mentioned under any section of the application criteria in published material from Ontario medical schools.9-14 In sections that spoke of qualitative assessments, there was brief mention that AdComs were not looking for any activity in particular within a personal essay or ABS. For example, UofT directly stated that, “there are also no specific activities that will give you an ‘edge’”.13 Overall, such disclaimers were only briefly mentioned, if at all, and there was no published policy on STEGH themselves in relation to medical school admissions. According to Dr. Dowell, a key driver behind this secrecy is the annual backlash admissions committees receive from unsuccessful applicants.35 Implications of Non-Transparency Regardless of the drivers towards secrecy, a lack of transparency can have several negative implications, particularly its implications on student perceptions of the role STEGH play in medical school admissions. The unclear nature of the selection process may generate a climate of distrust and the need for guesswork, rumours, and reliance on outside sources.37 External preparatory courses and volunteer-abroad companies use this reliance to market their programs to premedical students. For example, in 2015, KaplanTestPrepTM blogged about the importance of STEGH in medical school applications, explicitly stating that, global health experience, "will help you in your medical school applications”.38 This may give off the impression to students that any kind of global health experience is a vital additive to their resume. Transparent statements from AdComs can help deter these sentiments early on.

Increasing Transparency The ethical dilemmas underlying STEGH call for greater transparency in how admissions committees view and treat STEGH in the admissions processes.35-36 Little research has been conducted on which information outlets are most influential, however literature does indicate that all pre-admission interactions with medical schools play a critical role in student decision-making.39 As such, all current forms of policy publication could have the power to influence students to think critically about their global health experiences.

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Dr. Dowell stated that he gives a ‘spiel during open day’ as a way of actively deterring unethical STEGH. However, ‘open day’ discussions may be too late in encouraging critical thinking towards their extra-curricular activities as students may have already undertaken STEGH by that point. Therefore, The 53rd Week should advocate for greater transparency in both first point of contact publications (i.e. websites) or subsequent contact methods (i.e. open day, interviews).39

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Further primary research on student perception Research Questions Current literature review into how students perceive admissions practices and the role of STEGH was limited and rarely quantified. This lack of information leaves a wide gap in research evidence that The 53rd Week could potentially fill. We found the following questions to be pertinent in informing The 53rd Week's advocacy initiatives: 1. How do medical admissions committees perceive and evaluate STEGH? 2. To what extent do medical admissions policies influence student behaviour?

The significance of the first question lies in customizability of advocacy initiatives: policy changes need to be school specific, and as such, The 53rd Week must understand the political norms of each school it engages with. The second question, in relation to student behaviour, is arguably the crux of The 53rd Week's engagement with medical schools. The purpose of engaging medical admissions boards is not to simply change policies, but to influence students by changing policies. Furthermore, AdComs care about how they are perceived by both applicants as well as the general public, and would be more likely to implement change if such changes have the power to improve public perception of their programs.35 By understanding how these policies guide undergraduate behaviour, The 53rd Week will be able to prove which policy changes have the potential to maximize positive influence.

Moving Forward To begin exploring these questions, we have identified two potential courses of action: 1. Conduct an environmental scan of the “hidden curriculum” underlying admissions policies by contacting members of admission committees themselves 2. Conduct populations surveys to study student behaviour To start this process, we have begun to design a preliminary student survey, following the central research question of “To what extent does published admissions material influence student behaviour in relation to applying to medical school?”. The survey will assess these prospective applicants’ knowledge of admissions policy and their attitudes and behaviours in response to them. In addition, it will assess where undergrads gather information to guide their application process and which sources have the greatest influence.

We would strongly recommend that The 53rd Week continues this primary research initiative as these results could strengthen their advocacy platform to AdComs.

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CONCLUSION

In relation to STEGH, engaging in advocacy efforts towards medical admissions committees is an area of work that has seldom been explored in Canada, thus providing The 53rd Week a potential niche to fill in their organizational shift.

To help The 53rd Week move in this direction, we outlined four key recommendations for the organization to partake in: 1. The 53rd Week should advocate for admissions committees to move toward competency-based assessments of non-academic submissions; a. The 53rd Week should advocate for the use of external verification in assessing the quality of the autobiographical sketch activities; b. The 53rd Week should advocate for the use of CASPer and other moderated testing in lieu of traditional writing samples and essays; 2. The 53rd Week should adopt a social accountability framework in their advocacy initiatives towards admission committees; 3. The 53rd Week should advocate for admissions committees to be transparent on their stance towards STEGH activities; and 4. The 53rd Week should conduct further primary research on student perceptions of admissions committee policies and processes.

Although these recommendations may not address STEGH explicitly, they address broader issues within the medical admissions system that strongly influence the STEGH climate for pre-health students. Aligning with The 53rd Week’s values, we believe that these advocacy initiatives have the power maximize the benefits of good-intentioned volunteers, while diminishing the systemic injustices that arise within our current STEGH environment.

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REFERENCES

1. About | The The 53rd Week [Internet]. [cited 2016 Nov 27]. Available from: http://www.53rdweek.org/about 2. Melby M, Loh L, Evert J, Prater C, Lin H, Khan O. Beyond Medical “Missions” to Impact-Driven Short-Term Experiences in Global Health (STEGHs). Academic Medicine. 2016;91(5):633-638.

3. Deo R. The tragic rise of Gap year voluntourism [Internet]. The Independent. 2016 [cited 7 November 2016]. Available from: http://www.independent.co.uk/voices/comment/the-tragic-rise-of-gap-yearvoluntourism-8473608.html 4. Current Programs | The The 53rd Week [Internet]. [cited 2016 Nov 27]. Available from: http://www.53rdweek.org/programs 5. Loh L. Partner Organization Interview. Health Sciences Library; 2016.

6. Loh L. Good outcomes from good intentions: optimizing short-term volunteering abroad. 2016 Mar 9; University of Toronto.

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8. Medical School Application Statistics [Internet]. Ontario Universities’ Application Centre. [cited 2016 Nov 7]. Available from: https://www.ouac.on.ca/statistics/med_app_stats/ 9. Michael G. DeGroote School of Medicine [Internet]. McMaster University. 2016 [cited 1 November 2016]. Available from: https://fhs.mcmaster.ca/main/medschool.html 10. Northern Ontario School of Medicine - Application Information [Internet]. Nosm.ca.

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2016 [cited 7 November 2016]. Available from: https://meds.queensu.ca/education/undergraduate/prospective_students 13. Admissions | MD Program [Internet]. Md.utoronto.ca. 2016 [cited 7 November 2016]. Available from: http://md.utoronto.ca/admissions 14. Admission Requirements - Undergraduate Medical Education - Western University [Internet]. Schulich.uwo.ca. 2016 [cited 7 November 2016]. Available from: https://www.schulich.uwo.ca/medicine/undergraduate/future_students/admission/re quirements.html 14

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15. OMSAS - Autobiographical Sketch [Internet]. Ontario Universities’ Application Centre. [cited 2016 Nov 7]. Available from: https://www.ouac.on.ca/guide/omsassketch/ 16. Enhance Your Application With Your Extracurricular Choices | Kaplan Test Prep.

(2016). Kaptest.com. Retrieved 25 November 2016, from https://www.kaptest.com/mcat/medical-school/pre-med-extracurriculars 17. Lane, J. & Christensen, N. (2015). Competence is the Best Credential. Calgary: Canada West Foundation. Retrieved from http://2rs11m47n9nefk1rmiofa51a.wpengine.netdna-cdn.com/wpcontent/uploads/2015/04/Competence-is-the-Best-Credential.pdf 18. Medical Missions Database – medicalservicetrip [Internet]. [cited 2016 Nov 7].

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APPENDIX

Authors Information: Crystal Chan is a 5th year undergraduate student in the Honours Life Sciences program with a minor in Sustainability at McMaster University.

Jenny Lee is a 3rd year undergraduate student in the Global Health specialization in the Health Sciences program at McMaster University.

Ramachandiran Sethuraman is a 3rd year undergraduate student in the Global Health specialization in the Health Sciences program at McMaster University.

Emily Siskos is a 3rd year undergraduate student in the Arts & Science program at McMaster University.

Key Informants: Dr. Christopher Dainton is a Toronto-based physician with an interest in medical service trips. He has worked towards developing a database {medicalservicetrip.org} to assess the conduct of over 300 global medical aid organizations across North America which could be very useful if one wished to independently verify the quality of a medical aid organization. + http://medicalservicetrip.com/medical-missions-database/ Dr. Johnathan Dowell is a medical educator at Dundee University in the United Kingdom.

He has worked closely with their medical admissions team in developing their best practices for medical admissions and helped integrate the MMI into their admissions process. + http://medicine.dundee.ac.uk/staff-member/professor-johnathan-s-dowell Dr. Jessica Evert is the current CEO of Child Family Health International, a global health non-profit which specializations in sustainable medical aid to developing countries. She is also a co-founder of the Working Group on Global Activities of Students in Pre-Health (GASP) which is specifically concerned with the manner students in pre-health conduct medical aid trips. + https://www.cfhi.org/jessica-evert-md

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