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Introduction¹

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¹ The planning committee’s role was limited to planning the workshop. This Proceedings of a Workshop was prepared by independent rapporteurs as a factual account of what occurred at the workshop. The statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.

In the spring of 2024, the Global Forum on Innovation in Health Professional Education (IHPE Forum) at the National Academies of Sciences, Engineering, and Medicine held a multiday workshop titled Optimizing Recruitment and Admissions Strategies in Health Professions Education. The objective of the workshop was to consider the use of admissions strategies for ensuring a sustainable, high-quality workforce that is adequate in numbers, reflects the population being served, and is equitably distributed. Four workshop sessions were held, both virtually and in-person in Washington, D.C. The workshop was planned by a committee (see Appendix D) according to a statement of task (Box 1-1). The full workshop agenda is provided in Appendix C; biographies of the workshop planning committee and speakers can be found in Appendix D; and a listing of the members of the IHPE Forum that hosted the workshop is in Appendix B. It was the members of the IHPE Forum who discussed and later hosted this workshop with the aim of exploring how the admissions process could be more effectively used within and across the health professions to achieve the desired aims of institutions and organizations, while serving the needs of society. A question members pondered was whether any examples exist, from anywhere around the world, linking admissions to impacts beyond student or learner success. For example, would it be possible to admit learners with a desire to work with underserved communities and later conduct post-graduate measurements to determine whether those students had actually affected the social determinants of health? Members wondered what those measurements might be and requested a workshop

where examples could be shared, innovations linking admissions to measurable outcomes could be considered, and new ideas could be imagined for how the admissions process might be used. This proceedings is a written account of the workshop.

DEVELOPING A THEORY OF CHANGE FOR THE ADMISSIONS PROCESS

The first day of the workshop was held virtually on February 22, 2024, and focused on exploring whether and why a change in the admissions process would be beneficial for health professions education. Participants were welcomed by Halaevalu Vakalahi, president and chief executive officer of the Council on Social Work Education. Vakalahi began by saying that the opening session would be framed around a theory of change, in particular, a theory that sees change as starting with teams envisioning what success looks like and then charting out the steps needed to reach that goal. Vakalahi introduced the first speaker, who gave an overview

of the theory of change and how it would apply to health professional admissions.

Framing the Theory of Change

The admissions process for health professional education is part of a larger picture, said André-Jacques Neusy, a senior director at Training for Health Equity Network, operating out of Belgium. There is a crisis in human resources for health globally, which manifests in a shortage of health professionals, maldistribution within and across countries, and a lack of diversity in the health professional workforce. This is a multifaceted challenge, he said, and will require a comprehensive strategy to recruit, train, and sustain a fit-for-purpose workforce. Neusy explained that a “fit-for-purpose workforce” is one that has the competency, the willingness, and the commitment to address societal needs and to work where the needs are greatest. These characteristics are part of a social accountability mandate that all health professional schools would ideally have, he said. The point of entry to health professional education—that is, admissions—is a very critical aspect of creating this fit-for-purpose workforce.

In examining whether and how the admissions process for health professional education might be changed, using a theory of change provides several benefits, Neusy said. First, it provides a structured approach and a clarity of purpose that outlines the expected outcomes and the pathways needed to achieve these outcomes. Second, it is designed to be adaptable to accommodate change in the educational system, the health system, and in societal expectations. Third, it brings multiple stakeholders to the table, including educators, students, policy makers, community representatives, and health care professionals. Fourth, it involves a systematic literature review to look for best practices and to identify gaps in research. Finally, it provides a method for mapping out the causal pathways and key assumptions that underlie the system in question.

Neusy explained how the theory of change works. It starts, he said, by defining and articulating the long-term desired outcomes and goals. Incorporating multiple goals into a single theory can help ensure that the interventions proposed are holistic and will address the various facets of complex problems. The next step is identifying intermediate goals and identifying the strategies and actions that are needed to reach both intermediate and long-term goals. In addition, the process requires defining the preconditions that must be in place for change to occur and examining the assumptions that are being made. The final step, Neusy said, is proposing interventions and connecting the interventions with the long-term goals as a pathway for change. In essence, he said, the theory of change is like a logic model with timelines, responsibilities, and identification of the resources needed to effect change.

To apply the theory of change within the health professions admissions process, it is helpful to develop and monitor metrics that provide information on whether the workforce is fit for purpose. These metrics should not only monitor student outcomes during their education but should also look downstream to see if the education is reflected in the practice of health professionals that meet the needs of the community. For example, are health professionals working in underserved areas and addressing health disparities? Neusy emphasized that the theory of change process can look different for each institution because institutions have different contexts and different missions. However, the conceptual model of the theory of change is adaptable and applicable to any context.

Current Admissions Process and the Needs of Society

After Neusy framed the theory of change, a panel of health professionals and educators from the United States, Belgium, and United Arab Emirates reflected on the presented ideas from different perspectives. Vakalahi explained that the goal of the session was to describe the current admissions process, to examine whether it is meeting societal needs, and to identify what levers exist that could direct graduates toward meeting those needs. Vakalahi moderated the session by asking the panelists a series of questions.

Is the Current Admissions Process Meeting Societal Needs?

There are shortcomings of the current admissions process, said psychology consultant Daniel M. Elchert. In some places there are not enough health professionals, and in many places the health care workforce does not look like the community of patients that they serve. The distribution of providers across geographic regions is skewed; this often comes at the expense of individuals in rural communities who are unable to access care or to find a provider who is a good fit in the culture of the community. These problems with volume, diversity, and distribution of health professionals are major challenges that would have to be addressed to create a “fit for purpose” workforce, Elchert said. He encouraged everyone to be proactive about addressing these challenges. During the COVID-19 pandemic, the health professional education system responded to the crisis by adapting systems of admissions, education, and clinical experience. Instead of making changes in response to an immediate crisis such as the pandemic, Elchert said, the health professional education system could create a vision for the future and begin to lay the groundwork for changes that would result in a workforce that meets the needs of society. Neusy added that the problems of diversity and geographic distribution are related; he noted that it is a big challenge to recruit, admit, and retain candidates from regions in which the health care needs are highest.

How Might Admissions Take into Account the Different Contexts in Different Communities?

The admissions process is highly contextual, said Jan De Maeseneer, professor emeritus at Ghent University, Belgium. Countries with data and forecasting mechanisms could determine the needs of society, and health professional education systems could then translate these data into the numbers and skills required from different disciplines to meet the identified societal needs. De Maeseneer noted that these predictions would have to take into account issues such as task shifting, competency sharing, and technological developments. The process and strategy for planning health professional admissions are different for countries with publicly financed health systems than in countries with privately financed systems. De Maeseneer shared an example from his home country of Belgium. In 2006, only 94 family physicians graduated in the Flanders region, which is home to around 7 million people. This shortage prompted the passage of a law that mandated 42 percent of medical graduates be trained in family medicine. In addition to the law, other measures were put in place to incentivize applicants to go into family medicine. The pay for family medicine residents was raised to be equal to the pay for residents in other specialties. To address work–life balance concerns, a new position of “practice assistant” was created, and practice nurses were incorporated more extensively into the system to help distribute the work. Technical changes, such as the creation of an integrated health record, further strengthened the position of primary care. These initiatives, along with the efforts of universities demonstrating social accountability, resulted in the graduation of 380 family physicians in 2023.

Challenges in health professional education and health care can be addressed with multiaxial change strategies, De Maeseneer said. To do this, health professional institutions could look at the broader picture to see how they contribute to the challenges and what strategies they could use to make a change. In addition, governments could implement strong policies to transform health economics to deliver what matters, he said. Governments are responsible for setting goals, implementing laws to meet these goals, and creating an environment that stimulates change. Communities could also be involved in this process, he noted, adding that “participation of the population in the change process is extremely important to make the change acceptable and to make it effective.”

Eman Alefishat, Assistant Dean for Medical Education at the College of Medicine and Health Sciences, Khalifa University, United Arab Emirates, shared her perspective on health professional schools in the Middle East. In Jordan, pharmacy students can enroll in either a Bachelor of Science in Pharmacy (BSc) or a Doctor of Pharmacy (PharmD) program. The

admissions criteria for these programs heavily rely on grade point average (GPA), which can force some students to take a longer path to clinical pharmacy. The country needs industry and clinical pharmacists, but the admissions criteria do not distinguish between students’ interests and their career plans. Including required skills and assessing each candidate’s interest in the admission criteria would better align with students’ career goals and the country’s specific needs.

In the United Arab Emirates (UAE), Alefishat is also a founding faculty member at the only U.S.-style medical school in the country. She remarked on the school’s success in admitting a diverse class with students from around the globe. In addition to Emirati students, the school has enrolled students from 40 countries. One of the program’s goals is to train physician-scientists, aligning with the UAE’s emphasis on innovation and discovery. The admissions criteria reflect this goal. The first graduating class included several students interested in careers as physician-scientists. The university has also invested in resources to support this goal through student scholarships and other forms of assistance. These targeted admissions criteria help ensure that the school prepares health professionals to meet the country’s specific needs.

A Reimagined Admissions Process

Anthony Breitbach, representing the National Academies of Practice on the IHPE Global Forum, moderated the next session, which focused on re-imagining the admissions process. U.S. panelists from a variety of health disciplines engaged in a roundtable discussion around the following questions:

• What is the desired outcome you, your organization, or your profession is trying to achieve from the admissions process?
• When we think about a reimagined admissions process, how do you think that would affect the workforce moving forward?
• What role does your organization play?

Mark Anthony Merrick of the College of Health and Human Services at the University of Toledo began by noting that athletic training programs are different from some other health professional programs because they generally have the capacity for the number of applicants that they receive. Unlike other programs, athletic training education programs are not selecting specific applicants to fill spots; instead, they are competing to get enough applicants to fill the capacity. Because of this, Merrick said that he thinks of admissions as a recruitment and development process rather than a selection process. Through this lens, there is a strong desire to balance

the preparation of applicants with attracting applicants to the program. He explained that while there are entry requirements that ensure that applicants have the appropriate knowledge to be successful in the program, these requirements must not be so onerous that they restrict the entry of people into the profession.

The admissions process in nursing, said Patricia Francis-Johnson of the School of Nursing at the Texas Tech University Health Sciences Center, is aimed at identifying and recruiting compassionate and caring individuals who can complete the program successfully and pass the National Council Licensure Examination. Part of this process, she said, is ensuring that the applicants can meet the needs of the population that they will serve; that they will stay in the profession through “tough times”; and that they will be innovative and forward-thinking as learners and health professionals. Ultimately, the goal of nursing admissions is to build an inclusive workforce that reflects the needs of the population and the communities that are served, Francis-Johnson said. Nancy Spector of the National Council of State Boards of Nursing added her perspective as the director of nursing education. We need students with the attributes of reliability, competency, and integrity, Spector said. Nurses are with patients 24 hours a day; they need to be able to think critically about patient care and to detect and report any issues of safety or quality. In addition, nurses need to be compassionate and “love the profession and stay in it.” Currently, many nurses are leaving the profession, Spector said, and this may be partly related to the process in which applicants are selected. Better data on the outcomes of admissions would help make clear the links and thereby shape a more effective process, she said.

Peter Cahn of the MGH Institute of Health Professions said that, as a post-baccalaureate institution, the school has the admissions goal of bringing in students who will successfully complete the program and eventually become licensed in their field. Such students have the academic preparation as well as the compassion and skills to succeed. At the same time, as part of a large integrated health care system, the institution has a mission to improve the health of the community and the well-being of all people. This mission, he said, means that the admissions process sometimes requires “reaching back” to find potential applicants and helping prepare these individuals to take on the rigors of graduate education.

Helene Cameron of the American Association of Colleges of Osteopathic Medicine said that admissions in osteopathic medicine focus on finding applicants who believe in the osteopathic philosophy. She explained that this means practicing medicine with a distinct focus on the whole person through wellness. Around 25 percent of medical students in the United States are enrolled in osteopathic medicine programs, Cameron said, and their choice of program reflects a decision about what kind of doctor they

will be. Through the program and learning osteopathic manipulative medicine, Cameron said that osteopathic medicine students gain an extra tool in their toolkit that M.D. students do not have.

Naturopathic medicine is a small and emerging profession that focuses on identifying the root cause of health issues and addressing issues as naturally as possible, said JoAnn Yánez of the Association of Accredited Naturopathic Medical Colleges. The admissions process in this field is designed to identify and admit highly qualified and motivated candidates who will succeed academically and professionally and who have a genuine commitment to the principles of naturopathic medicine. An effective admissions process, she said, would “aim to excite the future generation to participate in health care.” Currently, there are multiple challenges facing many health professional education programs, including inspiring potential applicants to join the profession and ensuring that incoming classes reflect the diversity of backgrounds, experiences, and perspectives necessary to create a vibrant and inclusive learning environment. Naturopathic programs aim to select a diverse cohort of students to both enhance the educational environment and to prepare the workforce to effectively serve diverse populations and address the unique health care needs of individuals and their communities, Yánez said. The goal of admissions for naturopathic programs, she added, is to “recruit and admit candidates who have this potential to become competent, compassionate, and ethical naturopathic physicians who are contributing positively to the profession.”

A Reimagined Admissions Process

Breitbach asked panelists to reflect on what a reimagined admissions process might look like and how it could affect the workforce moving forward. Spector talked about two different threads within reimagining the admissions process in health professional education. The first would be to address applicants with fraudulent credentials. This happens in nursing as well as other professions, she said, and is a major challenge to the integrity of the professions. Spector said that a number of organizations are currently working on a policy paper on this topic; the paper is directed at educators and practitioners and emphasizes the need to carefully examine credentials and to verify letters of reference. Another issue within admissions, she continued, is a lack of data on the outcomes of admissions practices. One way to collect these data would be to give each applicant a unique ID. Providing a unique ID would allow data to be collected on which applicants are admitted, how admitted students perform in school, and where they go after graduation.

Francis-Johnson noted that one goal of admissions is to recruit and admit a diverse cohort of students. She commented on how an admissions

process that is strategic and intentional about recruitment would help ensure that future practitioners come from the diverse communities they serve. To accomplish this goal, recruitment would start early and look different. For example, kindergarten students can examine a stethoscope, middle school students can engage in conversations about what the nursing profession is, and high school students can receive guidance on how to prepare themselves to be competitive applicants for college and graduate education. “We need pipelines in place that will recruit and prepare the workforce for the future,” Francis-Johnson said, “and this requires being intentional and working with communities.”

Cahn said that being part of a system with 85,000 employees and 20 different health care organizations has shown him the “overwhelming” need for an educated health workforce. The MGH Institute for Health Professions grants degrees for professions at the master’s and doctoral levels, but it also has entered into partnerships with local community colleges, high schools, and elementary schools. Through these partnerships, the institution helps stimulate interest in the health professions, gives students exposure to a diverse range of professions, connects students with shadowing and mentoring experiences, and creates pathways for students who want to enter health professions careers at any level.

Merrick agreed that early engagement with students is critical to creating pathways to the health professions. The distribution of students’ interest in health professions does not match the educational capacity and demand in the professions, he said. For example, medical and physical therapy schools tend to have a surplus of applicants while athletic training and respiratory care have fewer applicants than are needed to meet the demand. Incoming students, particularly undergraduate students, rarely have sufficient awareness of the spectrum of health care professions and the qualifications needed to enter those professions. Aligning the supply and demand in health professional education is a major challenge, Merrick said. One approach that his institution has taken is creating a health sciences major that exposes students to a variety of professions and helps them find the right fit. However, he said, students’ ideas of their future identity in the health care system are often set before arriving at college. To address this issue, the university has partnered with a local magnet high school that focuses on health professions. The school was originally conceived as a pre-medical high school, Merrick said, but the partnership is working to ensure that students understand the full spectrum of health professions careers. In addition to these efforts to align awareness and interest with capacity and demand, Merrick said it is important to have a “catch net” for the students who apply to high-demand programs and do not get accepted. These students may feel as though they have failed, he said, and often do not know what their next step should be. There are plenty of jobs for them

in the health care system, but they need redirection and guidance to help them figure out where to go.

Cameron also spoke about raising awareness among potential applicants about the diversity of opportunities in the health professions. For example, there are many people who do not understand that there are two paths to becoming a physician—osteopathic and allopathic—so engaging with applicants early can draw their attention to the different options. Raising awareness can be done through partnerships with influencers, parents, advisors, counselors, and teachers. Osteopathic medicine has a focus on serving underserved communities, Cameron said, so it is critical to reach out to these communities to spread the word about the profession and to engage with potential future applicants.

Yánez agreed with other speakers about the need to raise awareness about the diversity of health professions but noted that students have access to more information than ever before. “With one phone in their hand,” students can find information very quickly; however, this information is not always accurate. Yánez said that it is incumbent upon all health professions to disseminate accurate information that is easy to find. Students are also asking “hard questions,” she said. For example, students may question the need to spend 10 years pursuing a degree and license. Health professional educators need to engage in a concerted public awareness campaign about the return on investment and the quality of life within health professions, she said. Many professions are facing headwinds with declining interest and declining readiness for health professions curriculum, and addressing this challenge would benefit learners and society by helping create a more diverse health workforce.

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