policy issues
Seeking inclusion in an exclusive process: discourses of
medical school student selection
Saleem Razack,1,2 Brian Hodges,3,4 Yvonne Steinert1 & Mary Maguire5
CONTEXT Calls to increase medical class repre-
sentativeness to better reflect the diversity of soci-
ety represent a growing international trend. There
is an inherent tension between these calls and
competitive student selection processes driven by
academic achievement. How is this tension mani-
fested?
METHODS Our three-phase interdisciplinary
research programme focused on the discourses of
excellence, equity and diversity in the medical
school selection process, as conveyed by key
stakeholders: (i) institutions and regulatory
bodies (the websites of 17 medical schools and
15 policy documents from national regulatory
bodies); (ii) admissions committee members
(ACMs) (according to semi-structured interviews
[n = 9]), and (iii) successful applicants (accord-
ing to semi-structured interviews [n = 14]). The
work is theoretically situated within the works of
Foucault, Bourdieu and Bakhtin. The conceptual
framework is supplemented by critical hermeneu-
tics and the performance theories of Goffman.
RESULTS Academic excellence discourses consis-
tently predominate over discourses calling for
greater representativeness in medical classes. Policy
Medical Education 2015; 49: 36–47
doi: 10.1111/medu.12547
Discuss ideas arising from the article at
www.mededuc.com discuss.
1 5
Centre for Medical Education, Faculty of Medicine, McGill
University, Montreal, Quebec, Canada
2
Department of Pediatrics, Faculty of Medicine, McGill
University, Montreal, Quebec, Canada
3
Department of Psychiatry, Faculty of Medicine, University of
Toronto, Toronto, Ontario, Canada
4
Wilson Centre for Research in Education, University of Toronto,
Toronto, Ontario, Canada
36
addressing demographic representativeness in
medicine may unwittingly contribute to the repro-
duction of historical patterns of exclusion of
under-represented groups. In ACM selection prac-
tices, another discursive tension is exposed as the
inherent privilege in the process is marked, chal-
lenging the ideal of medicine as a meritocracy.
Applicants’ representations of self in the ‘perfor-
mance’ of interviewing demonstrate implicit recog-
nition of the power inherent in the act of selection
and are manifested in the use of explicit strategies
to ‘fit in’.
CONCLUSIONS How can this critical discourse
analysis inform improved inclusiveness in student
selection? Policymakers addressing diversity and
equity issues in medical school admissions should
explicitly recognise the power dynamics at play
between the profession and marginalised groups.
For greater inclusion and to avoid one authorita-
tive definition of excellence, we suggest a transfor-
mative model of faculty development aimed at
promoting multiple kinds of excellence. Through
this multi-pronged approach, we call for the pro-
fession to courageously confront the cherished
notion of the medical meritocracy in order to
avoid unwanted aspects of elitism.
Department of Integrated Studies in Education, McGill
University, Montreal, Quebec, Canada
Correspondence: Saleem Razack, Department of Medical Education,
Montreal Children’s Hospital, 2300 Rue Tupper, C-429, Montreal,
Quebec H3H 1P3, Canada. Tel: 00 1 514 412 4475;
E-mail: saleem.razack@mcgill.ca
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 36–47
 Student selection: seeking inclusion in an exclusive process
INTRODUCTION
In the last decade, growing concerns at both national
and international levels have resulted in calls for an
increase in the demographic representativeness of
medical classes to better reflect the diversity of soci-
ety.1–3 Despite this, entry into medical school remains
highly competitive and exclusive of underprivileged
groups. A national demographic survey of applicants
to four central Canadian medical schools indicates the
exclusivity of entry to medical school and the success
rates of applicants reported in the literature lie
between 6% and 30%.4,5 Young et al.6 noted that the
proportion of students from families earning over Can
$100 000 per year was eight times greater than that in
the general population. In this study, students from
indigenous, Black and Filipino backgrounds, as well as
students from rural backgrounds, were also shown to
be significantly under-represented. In reality, despite
the recent calls to address the problem, these concerns
are not new, but have been raised both within the pro-
fession and more broadly within society regularly over
the last few decades. In situations in which a problem
persists, despite repeated calls for change, it is impor-
tant to consider the power dynamics that might be
operating to resist change.
The cherished ideal within the medical profession is
that student selection for entry into medicine func-
tions as a de facto and de jure system of meritocracy.
There is an inherent tension between calls to address
the demographic representativeness of the profession
and the competitive process of selection driven by
academic achievement. How is this tension mani-
fested in institutional discourses and experienced by
those who select for or apply to medical school? What
can an understanding of the discourses of student
selection from these multiple perspectives teach us
about meeting the challenge of achieving greater rep-
resentativeness in our medical classes?
‘Discourse’, a term used by many in the social sciences
and humanities disciplines, can play a central role in
regulating social institutional practices, including the
valuing and justification of certain actions over others.
Discourse can be defined as an institutionalised way of
believing, thinking and acting that includes allowing
social boundaries to define what can and cannot be
said about a particular topic.7 In an admissions pro-
cess to medical school, in which constructs such as ‘an
applicant showing potential to become an excellent
physician’ or ‘a medical school’s social accountability
mission’ are defined through discourses, this would
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include the making of judgements about which appli-
cants are most suitable for medical school and, from
the perspectives of applicants, the choices made in
self-representation during the various phases of the
student selection process.
How might the ideal of seeking the ‘best and the bright-
est’ be reconciled with the goals of fairness and equity in
the admissions process to medical school? Do stakehold-
ers experience these processes as competitive or comple-
mentary, or perhaps both? What are the implicit and
explicit messages about the profession’s valuing of the
concepts of ‘excellence’ and ‘equity’, and how are they
transmitted, internalised and constructed?
At the medical school that functioned as the setting
for this research, for instance, approximately 3000
applications must be culled down to 185 offers of
admission.8 For each individual applicant, it is
important to recognise that the practice of selection
results from the social judgements of multiple
agents (letter readers, file reviewers, interviewers,
etc.). We sought to understand the discourses
through which these judgements are enacted in the
selection process from the perspectives of appli-
cants, those who select, the institutions in which the
selection process takes place, and regulatory bodies
which help to define policy and practice. Our goal
was to uncover kernels of potential inclusiveness in
this inherently exclusionary process.
In this paper we synthesise a 4-year interdisciplinary
research programme through the conceptual lenses of
several traditions of discourse analysis, and focus on gain-
ing an understanding of the discourses of excellence,
equity and diversity in the process of student selection
for medical school. We are oriented towards an
approach that uses qualitative knowledge translation to
link theoretical and data-based research into selection
practices and policies in order to develop an evidence-
informed approach towards the addressing of inequities
and diversity issues in medical education, as these may
pertain to student selection.
METHODS
Theoretical framework
Foucault–Bourdieu–Bakhtin: the theoretical basis for the
discourse analysis
Throughout the three phases of the study, our
discourse analysis was grounded in the critical social
37
S Razack et al
and language theories of Michel Foucault, Pierre
Bourdieu and Mikhail Bakhtin.9–11 These three the-
orists’ works have provided the foundation that has
allowed us to deal with complex sets of data, includ-
ing written texts such as regulatory documents,
websites and applicants’ personal narratives, as well
as semi-structured interviews with admissions com-
mittee members (ACMs) and recently selected appli-
cants to medical school.
Foucault’s theory of discourse was notably helpful
in approaching the way in which discourses help
construct versions of reality. Foucault12 was specifi-
cally concerned with how, in a given set of social
conditions and history, it becomes possible to say
that certain things are ‘true’ and other things are
not. What is considered to be true is linked to
power dynamics that are embedded in discourses
and practices that are not always immediately visi-
ble to people involved in their (re)production.
Accordingly, discourses form objects and exist
through systems of distributions of power, which
can lead either to the reproduction of existing
structures or to the production of new ones.13
Foucault’s concept of discourse allowed us to
appreciate what he called the ‘conditions of possi-
bility’ for what agents of student selection and the
applicants who desire to be selected articulate in
their representations of self. Conditions of possi-
bility emerge as statements of truth (
e s) and
e nonc

make it possible to think, say and do certain
things and not others. Statements of truth in turn
can serve to generate ‘dividing practices’, or pro-
cesses that categorise, classify and separate individ-
uals. Discourses produced by organisations thus
imply the creation, maintenance and transforma-
tion of certain relations of power and control by
contributing to the definition of ways of believing,
thinking and acting, and of social boundaries that
define ‘who’ can say ‘what’ in a given context.
Inspired by the economic notion of capital, Pierre
Bourdieu discussed four kinds of capital: (i) eco-
nomic capital: material and financial resources at
the disposition of an individual; (ii) social capital:
the potential and actual resources associated with
the maintenance of a network of more or less insti-
tutionalised relations; (iii) cultural capital: the cul-
tural resources made available to a given individual,
mainly through his or her family environment and
schooling, and (iv) symbolic capital: any kind of
resource (social, religious, ethnic, associative, gen-
der-based, artistic, etc.) that is recognised in a given
society or group that contributes to the definition
of an individual’s social status.14
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Each of these different types of capital is operative
within a distinctive ‘field’, which refers to a rela-
tively autonomous game or competition for capital
that takes place through a configuration of objec-
tive relations that constitute an arena of the pro-
duction, circulation and appropriation of goods,
services, knowledge and status. Individuals may
occupy different positions of power depending on
their specific capital relative to each field. Accord-
ing to Bourdieu, different forms of capital interact,
and one’s standing in different fields as well as
the opportunities that are put at one’s disposal
derive from the outcomes of this interaction. Bour-
dieu’s theory of capitals helped to frame how dif-
ferent applicants’ experiences, backgrounds or
modes of preparation for the selection process
might be more or less valued by the admission
committee. It also contributed to a better under-
standing of the relationship between knowledge
and power in the context of student selection. In
fact, Brosnan15 discusses how medical education
and admission into medical school can be concep-
tualised as a field within which applicants’ portfo-
lios, personal narratives, curriculum or interview
answers can be understood as capital or market-
able commodities.
We worked with Bakhtin’s dialogic view of language,
in particular the concepts of ‘single-voiced’ (authori-
tative) and ‘double-voiced’ (internally persuasive)
discourses, in order to understand the mechanisms
by which language may be used to assert power. Sin-
gle-voiced or authoritative language (‘This is so. . .’)
‘is directed towards its referential object and consti-
tutes the ultimate semantic authority within the lim-
its of a given context’, whereas the double-voiced or
internally persuasive discourse (‘This may be so in
reference to that. . .’) inserts ‘a new semantic inten-
tion into a discourse which already has, and which
retains, an intention of its own’.16 The distinction
between these two types of discourse helped us to
understand how academic discourses come to pre-
dominate over service-to-society discourses, and then
to relate these to the social world through the
knowledge–power relation theories of Foucault and
Bourdieu’s concepts of the forms of capital. Exam-
ining the discourses in this way can help us to
understand how power might be asserted through
language in order to claim ‘truth’.
We chose this approach because we are theoretically
grounded in the notion that discourses regulate
social practices and the organisation of social insti-
tutions. More specifically, we were interested in
analysing how the selection of students for medical
 Student selection: seeking inclusion in an exclusive process
school represents a discourse community in the
field of medicine.
Figure 1 shows a graphical summary of this analyti-
cal framework.
Research questions
Phase 1. Stakeholders: institutions, credentialing and
licensing bodies
We selected a body of publicly available documents
pertaining to student selection practice from the
websites of Canadian medical schools and Canadian
medical education authorities, and credentialing
and licensure bodies, and examined these with ref-
erence to the following questions:
• In what statements of truth are the concepts of
‘excellence’, ‘equity’ and ‘diversity’ deployed
and used?
• What can be the significance of these statements
of truth for student selection practices for entry
into medicine in Canada?
Phase 2. Stakeholders: ACMs
In a pool of nine members of the selection commit-
tee for entry into the Faculty of Medicine at McGill
University, we investigated the following issue:
• How do participants understand, perceive and
use discourses of ‘excellence’, ‘equity’ and
‘diversity’ as they negotiate tensions between
these constructs in the medical school admis-
sions process?
Phase 3. Stakeholders: applicants to medical education
programmes
In a volunteer sample of 14 participants represent-
ing recently selected applicants to McGill University
Faculty of Medicine, we investigated the following
questions:
• What were participants’ intentions when engag-
ing with the different elements of the selection
process, especially the personal narrative and
the multiple mini-interview (MMI)?
• What do participants’ personal narratives indi-
cate about their beliefs, perceptions and repre-
sentations of the admission process, their
evaluators and medical school itself?
• How do these beliefs, perceptions and represen-
tations influence the way participants choose to
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Knowledge-power Types of knowledge that
relaonships ( ‘value’) can be ‘exchanged’ for
power (capital)
Interpreve
understandings
How these
‘transacons’ occur
authoritave versus
internally persuasive
discourse
Figure 1 Discourse analysis interpretive framework.
Foucault: appreciating ‘value’ through an analysis of
knowledge–power relationships. In looking at the website
texts with this concept in mind, we sought to answer
questions of institutional presentations of their own value
with respect to excellence, equity, and diversity. Bourdieu:
considering the exchange of ‘value’ through forms of
capital. Through this lens, we appreciated the ‘currencies’
of value as the different Bourdieuvian concepts of capital.
Bakhtin: analysing ‘transactions’ of value, through
language use, using the Bakhtinian concepts of
authoritative and internally persuasive discourse.
discuss, or not, certain elements of their back-
ground and life history?
Research phases
Each phase of the project was used to collect a
discrete set of data with distinct methods. Phase 1
represented a textual analysis of public documents
from the following sources: (i) the websites of Can-
ada’s 17 medical schools; (ii) certification, licensing
and regulatory organisations, which included 15 pol-
icy documents from five government and national
medical organisation sources (the Association of
Faculties of Medicine of Canada [AFMC], the Cana-
dian Medical Association [CMA], the College of
Family Physicians of Canada [CFPC], the Medical
Council of Canada [MCC], and the Royal College
of Physicians and Surgeons of Canada [RCPSC]). In
the first pass of our review of policy documents, we
also included provincial regulatory bodies, but we
found little in these in terms of policy related to
admissions to medical school.
We searched the websites and the documents for
mentions or discussions of the selection process,
equity, diversity and excellence. We sought to
situate each document within the context of
the organisation that produced it. We also sought
to develop an understanding of the statements
39
S Razack et al
of truth conveyed within each document and of
how the documents defined and discussed
the key concepts of excellence, diversity and
equity.
Having developed an understanding of the struc-
tures created by the discourses of excellence,
equity and diversity in student selection for medi-
cal school, both from the institutional perspective
and from the perspective of supra-institutional
medical education regulatory body policy docu-
ments, we next turned our attention to the role of
specific individuals’ agency within student selec-
tion. In Phase 2, we realised two open-ended struc-
tured interviews with nine ACMs at McGill
University medical school. In the interviews, we
explored their conceptualisations of excellence,
equity and diversity, and we invited them to
respond to texts from students’ personal narratives.
We were particularly interested in how discourses
at the more macro level were enacted in the praxis
of student selection, and in perceptions of tensions
and committee members’ resistance to and congru-
ence with these discourses.
Finally, in Phase 3, we carried out a textual
analysis of the personal narratives of students
recently admitted to McGill University’s Faculty of
Medicine and conducted two semi-structured
interviews with each of them to reflect on their
personal narratives and upon their representations
of self (‘performances’) during the interview
process.
Ethical approval to conduct the study was granted
by the Institutional Review Board of the Faculty of
Medicine at McGill University.
RESULTS AND DISCUSSION
Phase 1a. Institutional representations of
excellence: tension between discourses of the
academy and the service discourses of the
profession
We first turned our attention to the discourses of
excellence, equity and diversity present on the web-
sites of all of Canada’s faculties of medicine, particu-
larly those intended for potential applicants.17 From
this analysis, we began to understand the represen-
tation and valuing of these concepts within Cana-
dian faculties of medicine, and to hypothesise on
how the discourses represented might be positioned
within a wider historical perspective.
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Perhaps the most significant insight that we gained
from this part of the analysis was that medical
schools’ self-representations of excellence, as
observed on their websites, focused predominantly
on claims of excellence through scholarship,
research and knowledge creation. These pursuits
are important and laudable, but do represent, for
the most part, concerns of the academy rather than
those related to the profession’s role in service to
society. Moreover, the more centrically positioned
(more powerful and better endowed) particular
medical schools are in the field of sister schools, the
more predominant these authoritative assertions of
excellence become.
For the medical schools for which we see less use of
authoritative claims of institutional excellence
focused on the concerns of the academy, claims of
excellence show greater contextual nuance. We
observe greater appeals to service within the local
social context, which are presented as internally per-
suasive arguments, and most schools engage in a
mixture of authoritative and internally persuasive
claims of excellence to varying degrees. Excellence
in scholarship can thus be seen as holding more
value than and in tension with forms of excellence
related to social accountability within the field of
medical schools.
Medical schools seemed to define diversity (race,
ethnicity, gender and the like) as a quantifiable,
superficially observable commodity. This was gener-
ally accomplished through the visual representations
of student life on the websites, in which there
appeared to be obvious and deliberate attempts to
portray diverse student bodies, thus implying the
presence of sophisticated cosmopolitan learning
environments. In this way, diversity appeared to be
situated as a reified object within the discourses of
excellence and to derive from a White gaze. Deep
or hidden forms of diversity, such as particular indi-
vidual ways of thinking, seeing the world or being
that might result from the intersections of ethnicity,
gender, sexuality, socio-economic status and the like
were very rarely recognised or treated, if at all.
Equity, defined broadly as some recognition of the
need to correct historic or ongoing social injustice
(such as that related to Canada’s indigenous peo-
ples), was a vaguely defined concept when encoun-
tered on the websites. At the heart of this vagueness
were incomplete articulations of schools’ perceived
obligations to the societies or communities in which
they are located. What constitutes these communi-
ties? Who defines the school’s obligations to them?
 Student selection: seeking inclusion in an exclusive process
Overall, through the website analysis, it seemed that
dialectic tensions were evident in Canadian medical
schools’ website communications to medical school
applicants. A clear hierarchy of different forms of
excellence emerged in which university-type defini-
tions of excellence predominated over those related
to service to society. However, applicants are apply-
ing for professional training that carries with it an
explicit service-to-society mandate and, indeed,
often portray their suitability for medicine through
their service activities. We appreciated this discursive
tension in the definitions of excellence as having
the potential to create a conflation of understand-
ing between these two types of excellence.
It is interesting to speculate on the possible origins
of this conflation. One of the consequences of Abra-
ham Flexner’s report of 191018 was the obligatory
association of medical schools with universities.
Perhaps this influential and foundational document
for modern medical education in North America
may have sown the seeds for the future conflation
between university pursuits of academic excellence
and professional concerns of service excellence.
Indeed, in recognition of the need for greater atten-
tion to social accountability concerns in medical
education, Cooke et al.,19 in work commissioned by
the Carnegie Foundation around a century after
Flexner’s report, proposed significant changes to
medical education in the USA, including an
increased focus on service concerns. As the
pendulum shifts, with calls to enhance the focus of
medical education to better address important
concerns of service to society, the Carnegie Founda-
tion report can be seen as promoting a newer
conceptualisation of excellence in tomorrow’s doc-
tors in an attempt to bring resolution to the dialec-
tic tension among definitions of excellence.
The lessons learned from this phase of the research
can be summarised thus:
 scholarship, research and knowledge creation
predominate when medical schools write about
excellence, establishing a hierarchy among med-
ical schools;
 there is a dialectic tension between claims of
excellence and those of social accountability;
 diversity appears as a reified object, tokenised
into superficial features (race, religion, gender,
etc.) within the discourses of excellence, and
 equity remains vaguely defined.
With respect to medical schools’ communication
and messaging, what practical recommendations
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might address the dialectic tensions described
above? Based upon the analysis from this phase of
our research programme, we recommend that spe-
cific attention be paid to the potential of promoting
a false binary between traditional definitions of
excellence and service-to-society discourses. In
essence, we advocate for inclusive definitions of
excellence in which the concerns of the profession’s
service to society are integrally incorporated with
those in which the focus is more traditionally aca-
demic in nature. These inclusive definitions of
excellence would obviously need to extend beyond
communications on websites and other materials
into discourse–praxis links in student selection, and
ultimately into the curriculum for the students who
are selected.
Phase 1b. Policy documents: dysfunctional attempts
to resolve the tension
Having developed an understanding of institutional
discourses of excellence, equity and diversity, as
represented on websites, we next turned our atten-
tion to a more macro-level view of the discursive
structures to which medical schools in the Canadian
context are subject.20
We noted that diversity as a discursive object tended
to be represented as occurring within a discontinu-
ous history and thus as something new to society
rather than always present within it to varying
degrees, and as requiring a different approach
through a discursive shift. In addition, many of the
appeals for change referenced the concept of ‘social
accountability’ as the reason for the required
change, defining it vaguely, yet also as a quantifiable
and observable object. We thus observed the wide-
spread reification of this term as an argument for
change to student selection policies in order to
achieve greater diversity and equity. Finally, and per-
haps most saliently, when policies refer to the need
to address inequities, medical schools and the medi-
cal profession tended to be represented as ahistori-
cal and as outside the constellation of players within
society that may have had roles in the perpetuation
of the inequities in the first place. It was in this
observation that we noted some of the discursive
dysfunction of attempts at policy to improve the
demographic representativeness of the medical pro-
fession. In essence, this allowed for the profession
to be represented in ways in which its root struc-
tures, and the discourses that regulate them, need
not be questioned. Without critical dialogue on the
discourses regulating the social institutional prac-
tices (here, policy development), we questioned
41
S Razack et al
whether these well-meaning attempts at policy devel-
opment might ultimately contribute to the repro-
duction of the very inequities they seek to address.
The methodology of explicitly seeking to situate
policy development within relevant social, historical
and political contexts was useful in developing our
understanding of how we might change our prac-
tices with respect to policy development for greater
inclusiveness and decreased marginalisation. In
fact, we questioned how best to incorporate mar-
ginalised viewpoints within the design and develop-
ment of policy, and how to have a new
appreciation of how texts about underserved or
under-represented groups might actually serve to
continue to unintentionally exclude these groups
from positions of power relative to health and the
medical system. For example, dealing with ques-
tions of equity and diversity should explicitly take
into account the historical disempowerment of
certain communities and deal directly with the
redistribution of power relationships, through
critical reflection on the inclusiveness of the
process of policy development.
Our conclusions from this phase of the research
can be summarised thus:
 the documents analysed in this section present
diversity as something new;
 the concept of ‘social accountability’ is defined
vaguely, but valued as the reason for required
change, and
 documents present medical education, as well
as regulatory bodies, as ahistorical and as taken
for granted, which makes it difficult to integrate
alternative perspectives.
We have two practical recommendations for policy
development that derive from the work conducted
in this phase of the research. The first is that
policies that are intended to address inequities in
student selection for medical school, or indeed in
any of the service-to-society concerns relevant to
medical education, should explicitly recognise the
historic role of the profession and its institutions in
perpetuating the inequities the proposed policies
aim to address. This can be accomplished in multi-
ple contextualised ways, but could include the
giving of specific attention to committee member-
ship, the orientation of committee members, and
preambles in prospective policy texts that explicitly
recognise this historic role. Secondly, we suggest
that inclusive policy development be considered as
much more than simply ensuring that persons from
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marginalised groups are included on committees
that develop policy. The roles of such members
must be consciously empowered. This includes
attention to important roles such as chairing or
co-chairing, and explicit focus on the accountabili-
ties of policy developers. Specifically, developers of
policies designed to address inequities should ulti-
mately be accountable to the communities they aim
to serve, and policy development processes should
include community representation beyond simple
‘consultation’. Ultimately, policy developers in
medical education need to focus attention on the
imbalances of power in the actual process of policy
development. Reframing the discourse in this way
will go a long way towards the creation of inclusive
spaces in which previously excluded voices can be
heard and accorded their due recognition.
Phase 2. From the macro to the micro: how do
ACMs live the discursive tensions in their day-to-day
practice of student selection?
The selection of a student for entry into medical
school results from the social judgements of particu-
lar, and usually multiple, agents about specific appli-
cants’ suitability for medicine in various domains,
such as academic achievement and certain aspects
of character. These judgements can be understood
as enactments of the broader discourses identified
above.
In Phase 2, we focused on committee members’ com-
ments on the selection process and on applicants’
examples of personal narratives. In addition to our or-
ganising conceptual paradigm of Foucault–Bourdieu–
Bakhtin, in this phase of the research we integrated
insights about hermeneutic research drawn from the
Gadamer–Habermas debate concerning the nature,
goals and limitations of textual interpretation.19–21 We
justified the introduction of critical hermeneutics to the
analysis because we are ultimately interested in opportu-
nities for transforming student selection practices to
allow for greater inclusiveness, and the critical
hermeneutic method provided the means to explore the
possibilities of transformation. Although the Gadamer–
Habermas debate is highly complex, its core issue relates
to whether it is possible or desirable for social scientists to
critique established traditions. Gadamer argued that
people are limited by pre-understandings that condition
the meanings they take from their interactions with the
world. The range of interpreters’ ‘horizons of under-
standing’ is determined by their personal histories and
social contexts. However, although interpreters tend to
project their own fore-meanings onto texts, they can
broaden their horizons if they ‘examine explicitly the
 Student selection: seeking inclusion in an exclusive process
legitimacy, i.e. the origin and validity, of the fore-mean-
ings present within [them]’.21–23 In this way, we sought
not only to uncover the discourses of practice of ACMs,
but also to identify opportunities to transform their prac-
tice from critical reflexivity grounded in their interpreta-
tions of the ‘texts’ of applicant files and performances
through the selection process.
Through the analysis of committee members’ reflec-
tive interviews on their experiences in student selec-
tion, we appreciated that they negotiate a complex
terrain with multiple priorities as they attempt to
select fairly, with attention to excellence. Appropri-
ately and congruently with respect to the discourses
of institutional excellence, which we have identified
above as the discourses of the academy, committee
members saw the notion of a merit-based process as
central to student selection, and indeed implicitly
recognised this as a key factor in maintaining the
profession’s privileged role in society. Although they
recognised the importance of diversity and the need
to address historic inequities in the composition of
the profession, merit-based selection was seen as an
important value that must be protected and pre-
served within the process, and indeed the interplay
between the two was experienced as representing an
unresolved discursive tension. The following two
exemplar quotations from committee members
encapsulate this tension:
I’m saying that we cannot discount academic
performance. I mean, that frankly goes against
everything in a democratic society – understanding
that excellent performance is much easier if you
come from a wealthy household, whose parents
helped you with your homework since age three.
I think that the bottom line is that you have to
evaluate the candidates that come to you as indi-
viduals and in any given year you can’t start estab-
lishing all sorts of quotas and trying to get people
to fit into these little pigeon holes.
In the act of reflecting on their roles in the process
of selecting applicants for entry into medical school,
many committee members were also acutely aware
of both the implicit inequities in the system and the
critical role of the student selection process in
reproducing the ideal of medicine as a meritocracy.
At times in their reflections, the inherent privilege
in the process became marked: there was recogni-
tion of the fact that notions of merit, and of what is
seen as meritorious, are imbued with the complex
intersectionalities of class and privilege. At these
moments in which the privilege inherent in the
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process is marked, we can appreciate committee
members’ struggle with competing discourses:
. . .people seem to have a sense of quotas and
people seem to have a sense that someone less
qualified is being chosen over someone more
qualified. And. . . you would need to involve this
person in the conversation of how our notions of
‘qualified’ have tended to advantage [applicants
of] certain profiles and backgrounds.
Referring to the challenge of incorporating cultural
diversity education for psychiatric residents, anthro-
pologist Willen24 describes such uncomfortable
moments as ‘big gaping wound[s]’. In this example,
the wound is gaping because there is recognition of
the shaky ground of privilege upon which the cher-
ished notion of meritocracy rests. Within this discom-
fort, however, might lie the seeds of selection
practices that seek excellence (perhaps multiple
excellences) in equitable and diverse ways. Practically
speaking, critical dialogic engagement in which ACMs
can examine and problematise the base assumptions
characterising their selection practices may allow
members to lean into the discomfort of the ‘gaping
wound’ and to appreciate opportunities to transform
practices to facilitate greater social accountability.
From the work in this phase of the research, we
concluded that:
 members of selection committees negotiate
a complex terrain with multiple priorities,
but pay special attention to excellence, and
 there is a tension in their discourse between the
importance of diversity and the need to address
historic inequities in the composition of the
profession, and the notion of merit-based
selection.
Phase 3. The perspective of students: traversing
social distances through the reproduction of
privilege
An obvious other group of important social agents
within the process of selecting students for entry into
medical school consists of the applicants themselves.
In this last phase of the discourse analysis, we turned
our attention to their lived experience of the notion
of a merit-based selection process. At McGill Univer-
sity, student selection consists of a screening phase,
with academic file review and review of non-aca-
demic submissions (the curriculum vitae and per-
sonal statement). The interview process for those
successful in the first screen consists of MMIs.25 For
43
S Razack et al
readers less familiar with this assessment modality, at
McGill University the MMI consists of a series of 10
stations involving a variety of interactions, each of
which has a duration of 10 minutes. Some stations
involve interactions with actors, some with problem
solving, and others involve structured interviews on
various topics.
In this phase of the study, we were particularly inter-
ested in how applicants represented themselves as
desirable during the student selection process, espe-
cially during the ‘performance’ of interviews. Goff-
man’s26 theory of performance was central to our
analysis of applicants’ narratives about their experi-
ences of face-to-face interactions during the selec-
tion process. Goffman’s notion of performance
relies on a network of terms used to describe social
interactions, such as ‘audience’ (the observers or co-
participants who contribute to one’s performance),
‘part’ and ‘routine’ (the pre-established model of
actions that unfold through a performance, and
which are learned and moulded through socialisa-
tion), ‘front’ (what functions in a general and fixed
fashion and defines the situation for the audience),
and ‘setting’ (the background or decor). Any social
agent can be sincerely convinced that the impres-
sion of reality he stages is ‘real’ (the performance is
then said to present a high level of sincerity) or may
not be taken in at all by his own routine (the perfor-
mance is then said to be cynical). One’s perfor-
mance is based on one’s expectations relative to
others’ behaviour in a given situation.
What we noted most significantly was the complex
ways in which applicants negotiate their own identi-
ties, their perceived social distance from the possi-
bility that they might come to belong in the
medical profession, and the tensions in perfor-
mance between their own sense of authenticity and
the power of their audience (i.e. ACMs) to ulti-
mately say yes or no to their candidacy in medicine.
The role of the discourses of privilege is not lost on
them and is perhaps encapsulated best in this
quote, in which a student with an Italian Canadian
background talks about modifying his language for
McGill University, which he perceives as an ‘Anglo’
institution:
But it’s just how I was brought up but some peo-
ple just don’t understand that type of culture
and so you really don’t want to turn off a group
of non-Italians, Anglo type comp when you get
to McGill. I can imagine you [addressing the
interviewer specifically] coming from a different
background, coming to Canada, coming to McG-
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ill, lot of white, just a different type of personality
and it almost seems more civilised to act a cer-
tain way. And many people don’t understand
that just because you express yourself a little dif-
ferently.
Within this quote are the main themes that we
uncovered in the analysis of the reflections of admit-
ted students on their experiences in the selection
process. Students appraised their social distance
from belonging in medicine and developed deliber-
ate preparation strategies in order to address it. The
student quoted here reports having modified his
way of speaking, but we saw many examples of stu-
dents seeking ways to show values-based notions
such as ‘well-roundedness’ or ‘commitment to ser-
vice’. The analysis revealed a hidden curriculum
within the student selection process, one in which
the values of the dominant discourses of excellence
are transmitted to students, appreciated by them,
and result in deliberate performative practices dur-
ing the selection process.
Participants understand the profession as privileged,
and perceive scripted ‘intersections’ in behaviours
that are seen as appropriate or not in the MMI
selection process. These intersections are complex
and might include class, gender, language and, spe-
cifically in the context as an English-language insti-
tution in a predominantly francophone Canadian
province, ‘Anglo-ness’. In the selection process, par-
ticipants negotiated their own perceptions of social
distance or proximity from this authoritative norm
in their choices to be ‘authentic’ or to display
‘intentioned behaviours’. Our uncovering of a
significant hidden curriculum27 of privilege in the
MMIs revealed the process to represent a zone of
significant social contact in which participants inter-
acted with these authoritative discourses, and nego-
tiated new meanings for their own fluid identities.
In a sense, the student selection process can be seen
as part of a constellation of technologies of social
reproduction, or, restated from the points of view of
applicants, as an early act in the process of
professional identity formation that embraces the
complex social baggage that the profession brings
to identity formation through its dominant
discourses of excellence.
The analysis of applicant interviews in this phase of
the research afforded us the following insights:
• applicants negotiate their identities and their
perceived social distance from the medical pro-
fession;
 Student selection: seeking inclusion in an exclusive process
• there are tensions between how they negotiate
these features and how they perform their own
sense of authenticity, and
• participants understand the profession as privi-
leged and perform by following scripted behav-
iours that are seen as appropriate in the
selection process and involve aspects of class,
gender and language.
How might we address this hidden curriculum in
the student selection process? With respect to MMIs,
we recommend that explicit attention be paid to
the design of scenarios for contextual factors that
might introduce biases on the basis of class and
privilege, or which, when attempting to be diverse
and inclusive, do so from a ‘White gaze’. One
example of a potential bias in an MMI scenario
from SR’s own experience includes a suggested sta-
tion that aimed to assess conflict resolution skills in
the setting of a sailing team, clearly a context that
would be unfamiliar to many applicants. A second
example, again from SR’s own experience, includes
the design of a structured interview station in which
applicants discuss the health issues of Canada’s
indigenous peoples, in which the language used
treats indigenous persons as outside the profession
of medicine and pays no attention to the possibility
that the applicant pool might include persons of
indigenous backgrounds. We have found that
selection tool design processes that have an explicit
component in which these issues are critically
examined, and committee member training that
affords opportunities to discuss these potential
biases, are two important steps that should be built
into the practice of student selection to enable
greater inclusiveness.
Seeking inclusion in an inherently exclusive process
In this multi-perspective discourse analysis of the
selection process for entry to medical school we
have presented a complex phenomenon in flux
and in tension. We can appreciate a profession in
which the foundational narrative is one of meritoc-
racy, and the idea that it is ‘the best and the
brightest’ who should enter the medical profession.
Although this is not the only factor contributing to
the prestige of the profession, it is certainly an
important one in this regard. In strong counter-
point to the narratives of meritocracy lie the obser-
vations of the privileged social characteristics of the
individuals who join the profession, and the strik-
ing realities of the health inequities experienced by
persons from groups that are more excluded from
society.
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Perhaps tension is not a bad quality in the context
of the discourses of inclusivity and exclusivity in stu-
dent selection for entry to medical school. Tension
on a violin string has the potential to create beauti-
ful music. How can we use this potential tension to
improve student selection? We propose that it be
grounded in notions of critical reflexivity and an
understanding of the medical profession and its
institutions, such as university faculties of medicine,
as integral participants in histories of exclusion
within societies. As a discipline rooted in science, in
which notions of measurement and objectivity are
central, the tendency in medicine is to view the pro-
fession and its institutions as historic and as outside
the social forces that shape our world. Grounded
critical reflexivity in student selection should start
by challenging this view.
Specifically, we propose the following guiding prin-
ciples through which to evaluate and accredit stu-
dent selection processes for entry into medical
school:
 in the seeking of excellence, definitions of
excellence that integrate both the academic and
the service-to-society discourses should be
included;
 to support inclusiveness, the process of applying
to medical school is examined for its ability to
welcome persons from diverse backgrounds;
 the selection tools used should be aligned with
desired curricular outcomes, including those
related to service to society;
 fairness should be enhanced by ensuring that
potential biases are examined and addressed,
and
 transparency should be facilitated by clear
descriptions and knowledge of the processes
available to all candidates as an approach to
addressing power imbalances that may result
from the hidden forms of social and cultural
capital inherent in the selection process.
Explicit attention should also be paid to the hidden
curriculum of privilege that may be present in the
student selection process. This lies at the heart of
developing inclusive definitions of excellence. Inclu-
sive approaches can only be achieved through ACM
development which encourages critical reflexivity
and dialogue. We recommend as well that specific
attention be paid to inclusivity in the social space in
which student selection takes place, be that virtual
(such as on a website), structural (through policy)
or indeed real. Analysing the discourses of the selec-
tion process in this research programme allowed us
45
S Razack et al
to understand how selection might be understood
as an act of power, and as a technology for the
social reproduction of certain kinds of individual.
Within the Gadamer–Habermas debate, we found the
seeds of what a ‘critical pedagogy of faculty develop-
ment’, which promotes reflection on the role of medi-
cine in perpetuating inequities, might look like. With
respect to student selection practice, we propose a
model of critical faculty development in which con-
structs such as ‘an applicant showing potential to
become an excellent physician’ can be examined
through the lenses of privilege and capital. So many of
the important concerns in medical education today
refer to complex social phenomena and are, at their
base, calls for deep institutional transformations. In
this research, the case study in transformation is the
student selection process, but other equally relevant
examples of desirable deep transformations might
include notions of professionalism and professional
identity, addressing the needs of a diverse society,28–30
the promotion of generalism,31–33 and the preserva-
tion of the ‘art’ of medicine in these highly tech-
nological times.34 A model of critical faculty
development, based upon critical hermeneutic
instructional methods, and seeking of dialogic
engagement through ‘fused horizons’, as in the
Gadamer–Habermas debate, might provide the
means to accomplish change through the transfor-
mation of the understandings of discursive agents.
Moving from agency to structure, what can this criti-
cal discourse analysis teach us about improving
inclusiveness? We recommend that the processes of
developing policy to address issues of diversity and
equity in medical school admissions explicitly recog-
nise the power differentials that exist between the
profession and excluded groups, and build in the
consultative participation of such groups as policies
are developed. For greater inclusion, we suggest a
transformative model for the discourses of selection
to value multiple excellences rather than one hege-
monic definition of excellence. Through this multi-
pronged approach based upon our research evi-
dence, we call for the profession to courageously
make explicit the hidden aristo- or elitist aspect con-
tained within the merito- of the cherished notion of
the medical meritocracy.
Contributors: SR was responsible for the development of
the grant proposal for this work and the research
questions. All authors were involved in the elaboration of
the research from conceptualisation to results. SR
designed the methodology with the help of all
46 ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2015; 49: 36–47
13652923, 2015, 1, Downloaded from https://asmepublications.onlinelibrary.wiley.com/doi/10.1111/medu.12547 by University Of Manitoba, Wiley Online Library on [20/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
co-authors. BH contributed substantially to the Foucaul-
dian analyses, as well as to the methodology in which
performance theory was used. MM brought her expertise
in Bakhtin and her interdisciplinary perspective to the
design and analysis of the results. YS has expertise in fac-
ulty development and provided analysis related to knowl-
edge translation and applicability to the milieu of
medical education. SR drafted the preliminary versions of
the article. All authors contributed to the revisions of this
article and approved the final manuscript for submission.
Acknowledgements: The authors wish to acknowledge
research assistants Hourig Attarian, Lisa Trimble, Hadi
Karsoho, Lerona Lewis, David Lessard, Matthias Lalisse,
and Gabriella Djerrahian (Hourig Attarian and Lisa Trim-
ble were graduate students in the Faculty of Education,
McGill University. Lerona Lewis is a graduate student in
the Faculty of Education, McGill University. Hadi Kar-
soho is a graduate student in the Biomedical Ethics Unit,
McGill University. David Lessard and Gabriella Djerra-
hian were graduate students in the Department of Anthro-
pology, McGill University. Matthias Lalisse was a research
assistant at the Centre for Medical Education, McGill Uni-
versity.).
Funding: This work was funded through a grant from the
Social Sciences and Humanities Research Council of Can-
ada (grant no. 410-2010-1355).
Conflicts of interest: None.
Ethical approval: This study was approved by the McGill
University Faculty of Medicine Institutional Review Board
(approval no. A04-E21-10B).
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Received 24 December 2013; editorial comments to author 6
March 2014, 13 June 2014; accepted for publication 19 June
2014
47