The winding pathway to medical school: The role of non-direct routes in achieving a diverse student population

Introduction: Medical education has a responsibility to foster diversity, benefiting individuals, healthcare, and society. Admission procedures are often seen as central to shaping diverse student cohorts, raising concerns about bias and fairness. In this study, we take a step back and review different routes to formal eligibility: direct or indirect routes to meet the requirements to qualify for admission regarding the level of secondary education and the subjects that students have taken. We look at the effects of different routes to formal eligibility combined with the selection process on the composition of cohorts of medical students. Methods: We performed a longitudinal, population-based study in the Netherlands (2011–2022). Populations included: all first-year medical students, all pre-university graduates with the required subjects (the most direct route to eligibility), and the general population. Using chi-square goodness-of-fit tests (α = 0.001), we compared diversity across these groups by country of origin, and—for some comparisons—added socioeconomic indicators. Results: Medical school cohorts more closely resembled the general population than pre-university graduates. Students with a Dutch and Indonesian origin were most underrepresented compared to the general population; students with a Dutch origin were also underrepresented compared to pre-university graduates. Most other origins were over-represented or showed no significant difference from the general population. Discussion: Our findings show that diversity is diminished in the direct pathway to eligibility for medical school, and candidates with diverse backgrounds must follow winding pathways to formal eligibility. However, many candidates follow these winding pathways, as the diversity in medical school mostly reflects the general population’s. School-specific admission procedures do not seem to impede students from diverse backgrounds from getting into medical schools. Research and policy should study and remove upstream obstacles and support winding pathways, turning them into an asset for diversity.