Differential attainment within medical education: a systematic review

Background Differential attainment describes the systemic differences in outcomes when grouping cohorts by protected characterises and socioeconomic backgrounds. To date, most research studies have focused on a small number of characteristics and outcomes. This systematic review aimed to explore the association between a range of student/trainee characteristics and differential attainment in undergraduate and postgraduate medical education. Methods A systematic review was conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines with searches conducted in May 2023. Outcome measures were assessment, progression through training, and qualification in medical students or trainee doctors. Specific characteristics included were age, disability, entry route to medicine, ethnicity, gender, religion and socio-economic status. The Cochrane RoB tool, the Newcastle-Ottawa Scale and the GRADE approach were applied. A narrative synthesis was conducted due to heterogeneity between studies. Results Ninety-five studies were included. The majority were observational. There were over 381,815 medical student and 395,191 trainee doctor participants across all studies. The certainty across included studies was low and results were heterogeneous. Most results focused on assessment, followed by progression, then qualification. Gender, ethnicity and age were most commonly studied. Mixed results were noted for gender with results suggesting an advantage for undergraduate females however, females took longer to complete postgraduate training, and males were more likely to be on a specialist register. Minoritised ethnicity was consistently associated with lower attainment across a large number of studies. Younger doctors consistently did better in postgraduate assessments. Only 32 studies examined other characteristics with mixed results for disability and entry routes to medicine. The impact of socioeconomic status varied, but lower status was associated with lower attainment at later career stages. Conclusion Differential attainment is a complex, context-dependent phenomenon with multiple contributory factors that are challenging to disentangle. Despite low certainty of evidence, this review suggests that many characteristics do impact on outcomes in medical education. This warrants further investigation and indicates a need for monitoring and targeted differential attainment interventions to ensure equitable outcomes for medical students and doctors in training. Registration This systematic review is registered on PROSPERO, accessible at https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023426933 . PROSPERO has been updated to reflect the progression of this review. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-025-08197-1.