Older mature students’ experiences of applying to study medicine in England: an interview study

Older mature students’ experiences of applying tostudy medicine in England: an interview studyJonathan Mathers & Jayne Parry

CONTEXT Increasingly, medical schools areconsidering mature applicants, including grad-uate entrants. At present, the majority of ma-ture students are in their early or mid-20s andare entering medicine immediately or soonafter completing a first degree. However, ‘old-er’ mature students, who have worked in otheroccupations for a number of years, are alsoapplying to study medicine. Although it islikely that these students have particular needs,their experiences of applying to study medi-cine and related decision-making processeshave not been examined in detail to date.

METHODS Participants at three English med-ical schools took part in in-depth interviewsexamining their pathways into medical school.This analysis uses the findings from interviewswith 15 older mature students.

RESULTS This study demonstrates how oldermature students’ decision-making processesand experiences of application processesare heavily influenced by their personal

circumstances and backgrounds. Theirchoices are constrained geographically and interms of their identity, and also by percep-tions of the openness of some medicalschools to their applications. There are neg-ative implications for some students who areunable to secure places at their preferred‘local’ schools.

CONCLUSIONS Although the choice of med-ical school may be limited for this group ofapplicants as a result of their pre-existingpersonal circumstances, medical schools areperceived to differ substantially in their will-ingness to consider older students from variedworking and educational backgrounds. Theability of these applicants to join the medicalprofession may partly depend on geographicallocation. The provision of a central informationfacility outlining institutional requirements andpreferences would be a useful starting point,although it would be unable to address thebroad and complex range of issues that faceolder mature students.

admissions

Medical Education 2010: 44: 1084–1094doi:10.1111/j.1365-2923.2010.03731.x

Department of Public Health and Epidemiology, University ofBirmingham, Edgbaston, UK

Correspondence: Jonathan Mathers, Department of Public Healthand Epidemiology, University of Birmingham, Edgbaston, WestMidlands B15 2TT, UK. Tel: 00 44 121 414 6024;Fax: 00 44 121 414 7878; E-mail: [email protected]

1084 ª Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1084–1094

‘…and then I heard this medical school was openingand that it was going to be very different. They weregoing to take diverse students, and so I applied,thinking, ‘‘Well, if I apply … [that] … put[s] it tobed, [I might] not get a place, and that’s fine,’’ but Iwon’t go to my grave thinking, ‘‘Could I have doneit?’’’ (Interviewee 3; 42-year-old woman)

INTRODUCTION

Historically, entrance to medical school in the UK hasbeen dominated by young school-leavers, typicallyaged 18–19 years. In North America medical studentsare older and entry is restricted to graduates. In the1990s this system was adopted by medical schoolselsewhere, such as in Australia, with similar develop-ments in the UK gathering pace in the late 1990s andinfluenced by a rapid expansion of medical educationprovision, concurrent developments in curricula andmodels of delivery, as well as policy initiatives to widenaccess to medicine.1–5 New entry routes and courseswere opened up to mature students,6 including 16accelerated 4-year programmes specifically for appli-cants who already hold an undergraduate degree(so-called graduate-entry courses [GECs]).

In the UK medical students are typically referred to as‘mature’ at the age of 21 years or over and manymature students have entered medical schools viaGECs. Other options for mature applicants areavailable, such as the entry routes for applicants fromprofessions allied to medicine. A small number ofnew medical schools, established as part of theexpansion initiative and offering the traditional5-year programmes, have expressly acknowledged adesire to consider a broader range of applicants,including mature students.7

Debates about the desired attributes of prospectivemedical students and related entry criteria have ragedfor decades.8–11 Arguments that older students areparticularly suited to train to become doctors havecentred on assertions that they are more mature,committed to the profession and bring with themvaluable lived experience that provides relevantknowledge and skills.12,13

The majority of mature entrants to medicine inEngland are in their early to mid-20s.5 This reflectsthe availability of GEC pathways, to which studentsapply immediately or soon after the completion offirst degrees undertaken post-schooling. However,there are also ‘older’ mature applicants interested inpursuing a career in medicine, some of whom do

not come from health care-related backgrounds, maynot be graduates, or may be graduates in areas nothistorically thought to be relevant to medicine. Here,we use the term ‘older mature’ to refer specificallyto students who have worked in other occupations fora number of years prior to making a decision toapply to medical school. Admissions policies for thisgroup of students, who are applying to medicine laterin life after an extended period in alternativeemployment or careers, are not well developed atpresent. Experience elsewhere would suggest that theneeds of this group of older mature students aredistinct, and that lack of clarity in admissions policiesacross medical schools may disadvantage them.2

Mature students’ higher education decision making

Within the wider higher education (HE) literature,decision making related to HE participation, courseand institution choice has been theorised as beingqualitatively different for prospective ‘traditional’(e.g. middle-class school-leavers) and ‘non-traditional’(e.g. working-class or mature) students (for examples,see14–19). For the former, the transition to HE iscoherent with a ‘normal biography’, in which going touniversity is an automatic and assumed step along apathway to a well-defined and anticipated workingfuture.20,21 As such, it is suggested that decisionmaking is less complicated for ‘traditional’ studentsand is not typically associated with deliberation andanxiety. However, such transitions for working-classand mature students are understood to be lessstraightforward. Qualitative work demonstrates thatprospective entrants may perceive potential negativeaspects to, or consequences of, HE participation.15–17

Such perceptions and their impact on decision makingare intimately related to personal and social contextsand histories. For mature (particularly those returningto or considering HE later in life) and working-classstudents, such processes and transitions have beendescribed as a ‘risky business’.17 The move to HE is notstraightforward for many of these students and ischaracterised by the need to weigh up the risksinvolved, as well as the potential benefits.

Davies and Williams in particular have critiquedofficial and policy discourses which frame HE partic-ipation for mature students simplistically, in terms ofbenefits which are assumed to invariably accrue duringand after participation.15 Such discourses are arguedto construct mature students as rational actors,exercising a form of ‘technical rationality’, whichultimately is defined by policy and policymakers. Suchpolicy discourses, running alongside the move towardsmass education in the UK during the 1980s and 1990s,

ª Blackwell Publishing Ltd 2010. MEDICAL EDUCATION 2010; 44: 1084–1094 1085

Older students’ experiences of applying to study medicine

are criticised for failing to understand the specificcircumstances of mature students and the bases fortheir decisions around participation and choice ofinstitution, in particular. Whereas such policy dis-course might view non-participation as irrational inthe face of the clearly articulated benefits that will flowfor individuals, it is argued that we need to understandmature students’ decision-making processes as a formof ‘pragmatic rationality’. Such pragmatic rationalitydoes not assume that the espoused benefits of HEparticipation will naturally accrue and outweigh anypotential costs or risk. Rather, it explicitly acknowl-edges how personal, family and social contexts willinfluence the motivations of mature students to enterHE and impact on their ability to translate suchmotivations into action.15

Importantly, understandings of the processes under-pinning a ‘pragmatic rationality’ need to acknowledgethe risks that may be inherent in HE decision makingand that are particular to ‘non-traditional’ students.Examples of these for older mature students identi-fied in the wider HE literature include: the substantialfinancial and time commitments associated withstudy, including time spent away from families andchildren;15,19 the potential for some students, espe-cially those with poorer academic histories, to worryabout feeling out of place within HE and repeatingprior educational ‘failures’;16 concerns about thepotential for HE to isolate students from friends,families or partners as a result of personal change andtransition,18 and, related to this, the difficultiesinherent in maintaining a coherent self(class)-identity for working-class students during edu-cational transitions.16 These are weighed againstbenefits that might include enhanced employmentand career opportunities,15 particularly set againstdissatisfaction with current employment, the achieve-ment of related self-fulfilment via HE participation,16

and, in some cases, a desire to provide a positiveeducational role model for children and peers.17,19

At present no equivalent research has examined theexperiences of such processes of older mature medicalstudents in order to frame the further development ofrelated admissions policies and practice. In order tostart to address this deficiency, we present an analysisinvestigating the experiences and decision-makingprocesses of current older mature medical students,who have recently been through the process ofapplying to study medicine in the UK. In this study, wewere interested in unpicking the important facets ofpragmatic rationality during decision making aroundmedical courses for these students. In conceptualisingdecision making as a form of rational choice, we are

(like Davies and Williams15) arguing for a broadunderstanding of the basis for that rationality; webelieve ‘rationality’ should acknowledge importantaspects of applicants’ contemporary personal andsocial circumstances. Further, understanding ofchoices made should include an appreciation of theinfluence of biography on decision making in the hereand now, and how aspects of biography (e.g. personaland social circumstances) can result in dispositionswhich impact on such ‘choices’.22 Here, we attempt todo this in relation to the following questions:

• What are older mature students’ motivations forapplying to study medicine?

• What influences older mature students’ decisionmaking with respect to medical school applica-tions?

• What is the experience of this process like forolder mature students?

• What are the implications of current admissionspolicies for older mature students?

METHODS

This exploratory research was conducted as part ofthe National Evaluation of the Expansion of MedicalSchools (NEMS). The NEMS project was a wide-ranging, mixed-methods evaluation, which encom-passed work across all English medical schools, butfocused in-depth qualitative investigations on a smallnumber of case study schools. The work reportedhere was conducted as part of the case studies.

Three English medical schools participated as casestudy schools in the NEMS project. Two of theseschools are recently established and have admissionspolicies that explicitly attempt to reflect the wideningaccess agenda to include a proportion of studentswho do not come directly from secondary school;7

these have yearly intakes of approximately 130students. The third school is long established, admitsover 300 students per year and has an accelerated4-year programme for graduate entrants. All threecase study schools consider applicants from access-to-medicine courses and one has a limited number ofplaces linked with a local access course. Access-to-medicine courses are run by a number of educationalinstitutions in the UK and are designed for applicantswho do not have the required qualifications toapply to medical courses, allowing them to gain‘equivalent’ qualifications on a full- or part-time basis.When recruitment for the research took place, noquotas or other special-entry pathways were in placeat any of the schools.


J Mathers & J Parry

The NEMS project received ethical approval fromthe West Midlands Multicentre Research EthicsCommittee.

Identifying interviewees

We e-mailed all students at the three case studyschools asking for volunteers to take part in aninterview focusing on widening access to medicine.This invitation was not restricted to mature or oldermature students. In the e-mail we outlined the focuson access policy and indicated that we would like tospeak to students who felt they had something to sayon this topic. Each student who responded wasforwarded a standardised information sheet andgiven the opportunity to ask any questions about theresearch and the interviews, prior to agreeing totake part. A mutually convenient time and venuewere arranged with each student who agreed to beinterviewed.

The interviews

In-depth unstructured interviews were conductedwith each participant, by one of the authors (JM).Interviewees were encouraged to tell their ‘stories’about becoming medical students and to describetheir experiences as students to date. An unstruc-tured narrative style was used as a means of enablingparticipants to shape the interview by introducingtopics and issues interviewees felt to be most relevant,and also to investigate aspects of student biographieswhich might have relevance to prior and contempo-rary HE decision making. However, the interviewerwas also conscious of a number of key areas that hewished to explore via participants’ stories, concerningtheir:

• pathways into medicine;• motivations to study medicine;• social, educational and family backgrounds;• processes relating to the decision to study

medicine;• experiences of medical admissions processes,

and• experiences as medical students to date.

The interviews typically lasted 1.25–1.5 hours; thelongest took 3 hours. Interviews were tape-recordedwith the consent of participants (nobody refusedconsent) and transcribed verbatim. Notes were takenduring and immediately following the interviews.Demographic details that did not emerge naturallywithin the interview were collected at the end of theinterview (e.g. age, social class).

Analysis

We conducted analysis using the audio-recordings,transcripts and field notes. We performed a thematicanalysis of content based on questions underpinningthe research.

Prior to building a cross-case thematic frameworkcapable of comparative analytical questioning, weundertook within-case (each individual interview)coding and categorisation. We then built up athematic grid akin to that described in frameworkanalysis to enable cross-case comparisons based onsample characteristics, whilst retaining the ability tocheck within-case contextual validity.23 Although ouranalysis was primarily thematic, we were conscious ofand paid particular attention to narrative elementswithin individual interviews. Where appropriate, wealso recorded such within-case narrative analyticpoints related to the form or construction of thestoried accounts.24

JM conducted the initial analysis, coding and cate-gorisation. JP read the interview transcripts in theearly stages of this process and both authors tookpart in an iterative analytical process during whichcoding and higher-level categorisations were refined,prior to reaching a consensual view of the data andrelevant interpretations.

The interview sample

Of the 29 students who took part in an interview, 15were older mature students. Each of these studentshad worked for a number of years in other occupa-tions prior to deciding to apply to study medicine.Further details of these 15 interviewees, on which thisanalysis is based, are provided in Table 1.

RESULTS

Firstly, we characterise students’ motivations to studymedicine and the commonality in student narrativesaround periods in their lives prior to medical appli-cations. We then consider how students’ choiceprocesses are constrained, their experiences ofattempting to gain a place at medical school, andfinally the impact on students who do not gain placesat their preferred schools.

Motivations to study medicine

All but one participant talked about being moti-vated to achieve a stimulating and personally



rewarding occupation and career, by contrastwith mundane or ‘run-of-the-mill’ prior occu-pations. Interviewees 7 and 13 provide examples ofthis:

‘…but while I was working at the council, having hadmy first child, I knew that I wanted to change careers,

that I wasn’t happy with what I was doing, and it wasjust a stop gap really…’ (Interviewee 7; 36-year-oldwoman, White)

‘…seeing the future ahead now, I can definitely seemyself going places, doing what I want to do…’(Interviewee 13; 31-year-old man, White)

Table 1 Participant demographics and application details

ID Sex

Age,

years Ethnicity

Year of

study

Social

class

Prior

occupation

Entry

criteria

Previous

degree

Successful

in first

application

Schools

applied to,

n*

Offers

received,

n

1 F 34 Non-White 1 Middle Business Access course Yes Yes 1 1

2 M 45 White 3 Working Health care Health care Yes� Yes 1 1

3 F 42 White 3 Middle Health care Health care Yes Yes 1 1

4 F 38 Non-White 1 Working Environmental

health

Access

course

Yes� No

(2 rounds)

4� (4) 1

5 F 46 White 2 Working Teaching Bioscience

degree

Yes Yes 1 1

6 F 39 White 3 Working Medical

secretary

then IT

Re-took

A-level

Yes� Yes 2 1

7 F 36 White 1 Middle Council

worker

then PT

health care

Access

course

No Yes 1 1

8 M 35 White 3 Working In architect’s

office

Access

course

No No

(2 rounds)

2 (1) 2

9 F 40 White 1 Working Health care Re-took

A-level

Yes No

(2 rounds)

3 (1) 2

10 M 31 White 3 Working Teaching Unknown Yes Yes Unknown Unknown

11 M 30 White 1 Middle Teaching Bioscience

degree

Yes Yes 4 1

12 M 34 White 4 Working Armed forces Access

course

No Yes 4 2

13 M 31 White 2 Unknown Researcher Bioscience

degree

Yes Yes 4 Unknown§

14 F 37 White 2 Working Health services Access

course

Yes� Yes 4 1

15 M 34 White 1 Working Teaching Access

course

Yes No

(2 rounds)

4 (4) 1

* For students who went through two rounds of applications the figures in brackets refer to the number of schools applied to in the firstround� Returned to education as mature student� Applied to four local schools in first round of applications§ Accepted offer from preferred school upon receipt and terminated other applicationsF = female; M = male; PT = part-time; IT = information technology


J Mathers & J Parry

Interviewees also talked about the study of medi-cine as representing an opportunity to prove tothemselves that they could achieve. Interviewee 9described this as part of her decision-making processabout whether or not to apply to medical school:

‘Yes, once I had the idea… I knew the opportunitywas there; I sort of thought to myself: You can eitherstick at what you are doing and plod on. That’s theeasy option. You can just sit there, and then whenyou’re an old lady you’ll look in the mirror and you’llsay, ‘‘Maybe I could have done it, perhaps I couldhave done it.’’ And then I’ll feel angry that I didn’t doit and frustrated, and I thought, Well either you tryand if you fail you’ll be upset, but you’ll get over it.But at least you’ll know you’ve tried. At least you’llknow you had one last shot and it didn’t work.’(Interviewee 9; 40-year-old woman, White)

Although some interviewees cited incentives thatincluded long-term financial and job security, almostoverwhelmingly student narratives focused on self-fulfilment. Some interviewees talked about a long-standing interest in medicine, whereas others haddeveloped this over time through, for example,exposure to colleagues or friends working as orstudying to become doctors.

Considering medicine: the long road ahead

For most of these interviewees, applications to med-ical courses represented the culmination of a signif-icant period, often lasting years, of consideration andpreparation. A general pattern emerged from thestories of these applicants: alongside a motivation tostudy medicine, interviewees described periods of‘realisation’ that medical school might be a possibil-ity. For example, some talked about an increasingawareness of widening access and the acceptance ofmature students (e.g. via the media) by certainmedical schools:

‘…and then about 3 years ago I saw a televisionprogramme about the graduate course at [school]and my mum phoned me up actually and said, ‘‘Youmust watch this programme, you must watch thisprogramme.’’ Anyway, I watched it and sort of as I waswatching it I could sort of, you know, I started to sortof get excited and think, maybe it’s possible, maybeit’s possible. Anyway, I went to bed that night and Icouldn’t sleep, I just couldn’t stop thinking about it…I think I’d kind of resigned myself that it was too latenow, you missed the boat, and I suddenly thoughtactually you haven’t missed the boat [laughs] and

that’s really where it went from there.’ (Interviewee 9;40-year-old woman, White)

Interviewees then tended to describe a period ofweighing up the feasibility of becoming a medicalstudent. This included practical considerations aboutsuch matters as how they could satisfy entry require-ments and whether a period of full-time study wasfinancially viable, as well as considerations aroundschool choice described below. Several intervieweesalso talked about personal reflections on their suit-ability for medicine, about whether they were ‘goodenough’ to do it and whether they would be able to‘fit in’. Here, Interviewee 2 reflects on this followingadmission to medical school:

‘I’m sure that’s just a lack of confidence in a way,especially from me, I’ve never really had that muchconfidence in my own abilities and I just can’t believethat I’ve got this far, I just can’t believe it… And whenthey told me I’d got into this place I kept ringingthem up and saying, ‘‘Are you sure?’’’ (Interviewee 2;45-year-old man, White)

Choosing a school: limited horizons

Geography and family

Geography was a key influence on choice of schoolfor these students. Of the 15 older interviewees, 13cited university location as a determining factor intheir initial choice of schools. Ten had families; nineof these were married or had partners and one was asingle parent. Family was a prime consideration forthese interviewees, who tended to apply to ‘local’schools that would fit with established circumstances.Six students had school-age or younger children;five of these students were women. Each of thesewomen applied to local schools first, four to a singlemedical school, and one to four London schools.Three of these applicants were successful with localapplications:

‘The first year I applied to [school] because I’d gotsmall children and my husband was working locallyand he said, he really encouraged me and said, ‘‘Youcould do it, you should do it, but I’m not moving, Idon’t want to move.’’’ (Interviewee 6; 39-year-oldwoman, White)

‘I mean it [school] does happen to be convenientbecause it’s in the right part of the country for me,because I have got children and a husband soobviously although I could have possibly gone



elsewhere this obviously was my first choice.’ (Inter-viewee 3; 42-year-old woman, White)

Students who were married or had partners, but nochildren, also made initial choices that were geo-graphically determined. Although the intervieweeswith no immediate family ties made multiple appli-cations to more geographically dispersed schools,some still expressed a preference for schools closer tohome, where they would be able to avail themselves ofwider family, social and financial support:

‘…but I noticed they’d started doing it [medicalcourse] at [school]. Well, basically I live three milesaway from [school] and I thought, you know, if Icould get in here this would be a real possibility, afinancial possibility, because of course that’s theother thing, you know, how do you fund yourselffor 5 years? … So when the rejection came through Iwas absolutely… I was absolutely heartbroken, youknow, I mean this is where I wanted to be and thiswould have been the cheapest option for me and Ilike the medical school and, you know, I wasabsolutely gutted. Absolutely gutted.’ (Interviewee 14;37-year-old woman, White)

Identity and ‘fit’

Interviewees also described the influence on choice(pre-application or post-offer) of perceptions of howthey would achieve a ‘fit’ between themselves, thewider student body and the medical school culture.Most often, students talked about considering wherethey would feel comfortable as mature students.Experiences at open days or interviews were oftendiscussed, with ‘candidate’ medical schools beingthose at which a variety of students, usually in termsof age and working background, were encountered.Interviewees contrasted such experiences with thoseat schools at which they had felt like the ‘odd oneout’ or at which ‘mature’ appeared to mean ‘20-something’:

‘I stuck out like a sore thumb, you know; I was theonly mature person walking round, I was walkinground with all these school kids, and I justthought, oh dear, this isn’t – I just didn’t feel veryhappy about it.’ (Interviewee 14; 37-year-old woman,White)

Critically, for those students who applied to only onelocal medical school, this perceived ‘fit’ betweenindividual and institution was a major factor in theirdeciding whether or not medicine was a viableoption.

As well as maturity and prior working background,perceptions of medical school culture also influenceddecision making for some interviewees. For example,Interviewee 9 contrasted her experience to date as astudent at one of the case study schools, with herperceptions of another school that had offered her aplace:

‘I’ve really enjoyed it, it’s been really good, very nice,and the staff are nice and friendly and it’s verywelcoming here and the medical school [staff] arevery friendly, welcoming. And I think that’s really whyI chose to come here, because I felt like it was thekind of place I could be comfortable, that I could beme, that I wouldn’t have to pretend to be somethingthat I wasn’t, you know. And I thought in thatenvironment I will thrive, but if I went to a medicalschool which would be perhaps more traditional,more the typically White, middle-class public schoolmedical school, I don’t think that would have beengood. Because I got an offer at [school] and whenI looked there, that’s how I felt. I felt that I would bethe oddity [laughs] I would be… it was very White. Itwas very middle class. We had a visit round and themedical student who took us round said, ‘‘These arethe beautiful houses at [area]’’ and ‘‘This is thebeautiful school and when you’re consultants you canlive here and send your children to this beautifulschool.’’ And you know… I said, thank you, but I justthought I wouldn’t want to live here and I wouldn’twant to send my children to this school. But it waskind of the assumption, do you know what I mean,that we’re medics and this is what we’re going to do,and this is how you’re going to live your life, and I justfelt, I just didn’t feel right, I just felt like I was beingintimidated. And I didn’t feel that here at all.’(Interviewee 9; 40-year-old woman, White)

Here, Interviewee 9 is describing a judgement notonly about her ability to achieve a ‘fit’ between herselfand medical school culture during her studies, butalso about identities and behaviour that she is willingto adopt during the process of becoming a doctorand beyond.

Finding a way into medicine: variable experiences ofinstitutions and entry routes

As we have shown above, several participants talkedabout periods of investigating the feasibility ofembarking on the study of medicine. These periodsincluded making enquiries to medical schoolsabout their suitability as applicants, about potentialroutes in and about means to satisfy entry criteria.Interviewees often reported negative reactions to


J Mathers & J Parry

enquiries from certain medical schools, which theyattributed to their age (as too old) or their atypicalbackground or working history:

‘I think… I spoke to somebody at [school] … And itwas almost, the conversation was: there’s not ahope in hell of you coming here. He didn’t say it, butit did feel like that, the way he was talking to me. Thiswas the first time round when I was just askingwould… And I thought, okay, I won’t put you downthen… And at [school] I got that impression as well,even though [school] do accept an access course,there were some e-mail exchanges, there was noconversation and it was almost: don’t bother … It wasjust the same sort of thing. And you do, you get a feelfor where you can and can’t go.’ (Interviewee 4; 38-year-old woman, non-White)

Two interviewees further illustrated this perceptionby saying they had received only small numbers ofresponses to e-mails and written enquiries sent to allUK medical schools.

Overall, this resulted in negative perceptions amongstthe interview sample regarding the openness ofcertain medical schools to mature students andstudents from atypical backgrounds. Several inter-viewees, especially those who had applied via access-to-medicine courses, indicated that they felt certainschools were ‘no-go’ institutions.

A number of participants indicated that they hadconsidered GECs as a natural pathway for them. Ofthese, five had applied for GEC places, but only onehad been successful. This resulted in a view that GECplaces were mainly restricted to a particular ‘type’ ofstudent, typically recent and younger biosciencegraduates:

‘I mean truly they still really wanted people withscience degrees, you know, they wanted a sciencebackground… I think they were paying lip service to[the notion of] wanting people from wider areas oflife, but they really didn’t.’ (Interviewee 6; 39-year-oldwoman, White)

Generally, therefore, graduate-entry routes were notviewed positively by this cohort. Some intervieweeswent further, stating that they believed that schoolswith GECs and traditional courses considered the GECto be the main vehicle for widening access, and that 5-year courses were thus less open to mature applicants:

‘I kind of got the impression that the medical schoolsthat were running, or getting together a 4-year

graduate-entry course, that was their idea of where…if you were mature students, that’s where you werewanting to go. Because there would be very, very fewmature students who wouldn’t have a first degree,whatever it might be. And so the likes of [schools] …I think, does [school] do one? Anyway the ones thathave big traditional 5-year courses, because they weresetting up a 4-year graduate course, that was kind of…I think that it was also a case that for the 5-yearcourse, that was still for the 18- and 19-year-olds. Andif you were a graduate, yes competition was stiff toget on them, and certain numbers required some sortof medical slant to your first degree, which for me,as a mathematician, basically prevented me fromapplying. But I got the impression that that was theirget-out clause for accepting mature students.Whereas because the new medical schools were onlyrunning a 5-year course, they didn’t, for whatevertheir reason or reasons, they didn’t feel it necessary tosay, well, we only want 18- and 19-year-olds.’ (Inter-viewee 15; 34-year-old man, White)

Strategic applications

In relation to the experiences and perceptionsdetailed above, several interviewees described makinga strategic approach to their chosen schools. This wasbased, for example, on reactions from schools toinitial enquiries, knowledge of schools to whichprevious access-course students had made successfulapplications, and informal information gatheredfrom other applicants. All of the students who wentthrough two rounds of applications became strategicin their choice of schools during the second round.Three of these interviewees, who had talked aboutstrong geographical preferences, applied to ‘friendly’medical schools (those perceived to be open toapplications from mature students and students fromatypical working backgrounds), as well as theirpreferred local schools during their second round ofapplications.

Inflexibility and uncertainty of application processesfor mature students

An important aspect of the decision-making processfor these students refers to access to relevant knowl-edge and experience of what comprises the basis of‘good’ applications to medical schools. The Univer-sity College Admissions Service (UCAS) process wasseen to be designed for school-leavers and wasperceived as inflexible by several of this cohort.Interviewees also related uncertainty about therequirements they needed to satisfy in order toformulate ‘good’ applications (entry criteria, work



experience, how working background would beviewed, whether to supplement A-levels or go via anaccess route). There was a general perception that nocentral source of knowledge could be accessed and,further, of a lack of consistency and transparency onthe part of medical schools regarding which studentsthey would consider and under what circumstances.For such reasons, and especially for applicants com-mitting to full-time access-to-medicine courses,deciding to change career is a ‘risky business’ whichrequires candidates to make commitments and sac-rifices (e.g. giving up existing paid employment,moving home) without the certainty of a place atmedical school at the end of it:

‘Well, at the time it’s a case of like, you know, you’rerunning and you jump off the pier, you don’t know ifthe tide’s in or there’s rocks below, and it’s like well,you know, you’ve just got to say okay, you’ve just gotto go and jump, you know, and if things work outthen the tide’s in, but if not then it can all go horriblywrong. And that’s the sort of commitment thatpeople are making, you know, even on the accesscourse they’re on, they’ve given up their jobs, thrown[in] their entire life savings to support themselveswhen they’re doing it and all this sort of thing, andthat’s the sort of thing that’s going on. So, and I thinkobviously some medical schools sort of realise that’swhat people are doing, but I don’t think there are alot of people on the outside realise that actually that’swhat a lot of the sort of mature students who comefrom other backgrounds are actually making thosesorts of commitments just for a chance to studymedicine.’ (Interviewee 8; 35-year-old man, White)

The narratives of several of the interviewees werecharacterised by descriptions of the uncertainty andrisk involved in attempting to gain a place at medicalschool, such as Interviewee 8’s use of the metaphor of‘jumping off the pier’. These were often accompa-nied by narrative themes of personal struggle, com-mitment and determination in the face of barriers(e.g. unwelcoming medical schools).

Failing to get a place at a local school exacerbates thesacrifices made by older mature students

Two of the women with children had relocated theirfamilies after failing to obtain places at their pre-ferred local schools, which had resulted in consider-able upheaval. For one, this was facilitated by havingfamily in the area to which she moved and a husbandwith a job which did not have geographical ties. Forthe other, a single parent, and one of only two non-White interviewees, this required moving herself and

her mother (for child care purposes) to the area awayfrom family, friends and cultural resources:

‘For me, myself as well, I found that quite difficult. Ithink I felt very isolated… just [that] I’d taken myson away from his friends at school, I’ve uprootedmyself from a job, it was like there, it was like, ‘‘Oooh,reality’’ … Damn hard. Damn hard because she’s[interviewee’s mother] Black, and there’s not a verybig Black community up here.’ (Interviewee 4; 38-year-old woman, non-White)

Although financial considerations were in the fore-ground for a large proportion of this cohort, twostudents felt these had been greatly exacerbated as aresult of not being able to gain places at nearbyschools:

‘You haven’t really got a lot of back-up financially, youknow, and you know you’ve got these other guys who –they think they’re hard [up] financially poorly off –but they’re not really, you know, they’ve got, you know,a boyfriend or parents who can help them out now andagain or, you know, they haven’t got to pay the fees,you know, it’s like suddenly going for a cup of coffeefor £1 is a major problem, you know, it’s a pound youdon’t really – I know it probably sounds ridiculous…but you think I don’t really want to go for a coffeebecause I don’t really want to spend £1, you know, itgets like that… or people mention a night out, you’rethinking, oh God I can’t really afford it, you know.’(Interviewee 14; 37-year-old woman, White)

DISCUSSION

Study limitations

We interviewed students at three schools participat-ing in a wider national evaluation, two of whichhave expressly implemented admissions policiesdesigned to accommodate this category of appli-cant. As a consequence, it is difficult to infer thatthe narratives portrayed here represent the experi-ences of all older mature students. However, theinterviewees described personal circumstances (e.g.family and geographical commitments) which arelikely to apply in a similar manner to a largeproportion of older applicants and which, in turn,heavily influence decision-making processes andrelated experiences.

Further, we were able to include only current medicalstudents, not those who might have consideredapplying to study medicine, but ultimately decided


J Mathers & J Parry

against it, or those who tried and failed to gain placesat medical schools. Although we are able to infercircumstances that might be relevant for such stu-dents and that might prevent applications fromsuitable candidates, further work with students whoconsider medicine but do not apply is needed.

We have presented a primarily thematic analysis here,although relevant narrative analytic points werenoted during analysis and have influenced thethematic interpretation presented. However, furtherstructured narrative analysis may provide furtherinsights into how older mature students understandthe transitions to medical school, and would repre-sent a useful line of further enquiry.

Previous research and theoretical interpretations

As in previous research with non-traditional entrants toHE,15,16 self-fulfilment was a key aspect of the narra-tives of our interviewees, to be achieved via a move tomedical school and into the medical profession. Wecan conceptualise the decision-making process to-wards this goal, around participation and choice ofinstitution, as a form of ‘pragmatic rationality’.15 Suchrationality foregrounds individuals’ present family andsocial circumstances, but acknowledges how priorsocial and educational backgrounds bear influence ondecisions made in the here-and-now.

Unlike the straightforward processes that are moretypical, for example, for middle-class school-leavers,the outcomes of these decision-making processes arepotentially costly and involve inherent risk.15–17 Forthese interviewees, that risk can involve committingsubstantial financial resources to their chosen courseof action, and moving family away from establishedhomes and social networks. Importantly, as well asthese obvious practical implications of participation,there is commonly a need for students to undergosubstantial identity shifts that enable them, firstly, tocontemplate medicine, and then to make successfultransitions to medical courses. Davies and Williams,15

in work with mature working-class students consider-ing (non-medical) HE participation, suggested thatindividuals go through a process of constructing a‘learner identity’, whereby self-image is re-framedagainst negative prior educational experiences. Inthis study we see analogous processes for a number ofparticipants who have constructed an equivalent‘potential doctor identity’ over time, allowing them tobegin to consider applications to medical school.

Once mature students see themselves as potentialdoctors, pathways into medicine and, in particular,

institution choice become important. Geography iskey and many older mature students have a strongpreference for local medical schools as a result ofpersonal circumstances. However, a need to establish‘fit’ between institution and individual is also evident,with elements of identity (e.g. age, class) playing arole in such judgements. Reay has argued that a keydifficulty in this transition to education for manymature working-class students in wider HE involvesmaintaining an authentic ‘sense of self’ that is rootedin previous identities (e.g. a working-class identity):‘Risk and reflexivity for working-class studentschoosing higher education is about being differentpeople in different places, about who they might beand what they must give up.’16

We saw evidence of this in our interviews. Forexample, Interviewee 9 actively rejected the assump-tions tied to participation at one medical school andthe personal transitions that would imply. In addi-tion, those students who had been unsuccessful withlocal applications talked about the negative conse-quences of this and the sacrifices they had made togain places to study medicine, including the loss ofimportant personal resources that had become geo-graphically distant. This would suggest that prefer-ences for local schools are not rooted only in practicaland economic considerations, but also in the desireto maintain a coherent sense of self during thesubstantial personal transitions demanded byparticipation in medical courses. Stability in locationand the ability to remain ‘local’ during this time mayease these transitions.

CONCLUSIONS

Nationally, HE is emphasising the need to widenparticipation and, in the UK in particular, to broadenthe demographic base of elite professions such asmedicine.25 One small but important group of peopleaffected by widening participation policy includesolder mature applicants wishing to study medicineafter previous careers in non-medical or health care-related employment. This group of potential studentshas complex needs arising from their pre-existingsocial, family and economic circumstances and thusmay need to take substantial risks in attempting togain admission to medical school.

These challenges and risks are made all the greater bythe lack of a common source of information aboutthe various schools’ entrance policies for oldermature students. Previous work has suggested thatvariation in admissions criteria and processes existbetween institutions in regard to traditional 5-year



courses,26 but our interviews suggest that even greaterheterogeneity in institutional attitudes (and require-ments) pertains to older ‘atypical’ students.

The issues outlined here are complex, multifacetedand related both to the students themselves and to thepreferences and cultures of individual institutions.From an educational policy perspective, given theraised expectations promoted by wideningparticipation activities and policies, and in view ofthe challenges faced by potential students, the provi-sion of a central information facility that would clearlyoutline institutional requirements and, importantly,preferences, would be a useful starting point.

However, this alone is unlikely to resolve the complexset of issues that impact on older mature students,particularly in terms of their current perceptions ofmedical school admissions policy as somewhatrepresentative of a ‘postcode lottery’.

Contributors: JM and JP conceived and designed the study.JM conducted the research interviews, undertook the initialanalysis and interpretation of data, and wrote the firstversion of this manuscript. JP contributed to the analysisand interpretation of data and to revisions of themanuscript. Both authors approved the final version of themanuscript.Acknowledgements: this study forms part of an independentevaluation of the expansion of medicals schools. It wascommissioned by the Department of Health (DoH) PolicyResearch Programme and the Higher Education FundingCouncil for England (HEFCE) (project ref. 0160056). Theviews expressed in the paper are those of the authors anddo not necessarily reflect those of either the DoH orHEFCE. The authors would like to thank the students whoparticipated in this study for giving up their time and forbeing so willing to tell their stories. We sincerely wish themevery success for the future.Funding: this study was supported by the DoH PolicyResearch Programme and the HEFCE.Conflicts of interest: none.

Ethical approval: this study was approved by the WestMidlands Multicentre Research Ethics Committee (ref.04 ⁄ MRE07 ⁄ 58).

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Received 29 July 2009; editorial comments to authors 16 September2009, 12 January 2010; accepted for publication 1 April 2010


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Documents

Older mature students’ experiences of applying to study medicine in England: an interview study