Approaches to ensure an equitable and fair admissions process for medical training

The United States is projected to have physician shortages of 18,000–48,000 in primary care and 21,000–77,000 in non-primary specialty care by the year 2034¹. These potential shortages coupled with a population that is rapidly changing with respect to sociodemographic characteristics pose a serious challenge for patient-centered medicine. The medical community has argued that educating and training diverse learners in environments that intentionally facilitate learning across different sociocultural groups will address and correct health disparities among underrepresented populations by providing more culturally responsive and humble care^2,3,4. The 2023 Supreme Court of the United States (SCOTUS) ruling on affirmative action prohibiting the use of race as an independent factor in university admissions decisions means that other characteristics such as motivations, background experiences, and personal characteristics are even more important. Ideally, these applicant qualities are aligned with each school’s institutional mission. Expanded recruitment, updated and equitable admissions processes, and enhanced student support can help medical schools meet the present and future needs of our society.

While effective strategies to build a physician workforce may begin quite early in education, it takes decades for primary and secondary school interventions to yield results. Immediate positive changes can be implemented if the focus is on medical school admissions. Many decisions are made in admissions offices which accumulate to have large collective effects. Because admission to medical school is competitive, with more than twice as many applicants as places, cultivating a large and diverse applicant pool is insufficient. Medical schools should also identify and correct inequities that exist in the admissions process that can exclude applicants who have excellent potential. For example, US medical student trends from 2007 to 2017 have shown that roughly 24%–33% of medical students came from households in the top 5% income level nationally, compared to roughly 5% of medical students from households in the lowest 20% income level⁵. Similar disparities exist for medical students based on race/ethnicity and first-generation college student status^6,7. One can conclude the admissions process is not designed to promote those who have been historically marginalized in the medical community.

Medical school faculty are predominantly white and these individuals determine admissions standards, select, mentor, and educate the students⁸. Virtually all medical schools agree that diversity is an imperative. The 2021 Association of American Medical Colleges (AAMC) Admissions Officers Survey found 98% of institutions reported contributing to a diverse physician workforce as an important aspect of their educational mission⁹. Additionally, 95% of institutions reported using holistic review to assign balanced weights to the primary domains they consider as part of each applicant’s portfolio, such as academic metrics, backgrounds, lived experiences and personal characteristics. Yet, despite these goals and practices, relatively little progress has been made nationally in diversifying the workforce and achieving equitable health outcomes^10,11.

In this article, we describe what we believe is both missing and necessary to advance diversity in medical education. To effect real and enduring change, medical schools must embed equity into every aspect of admissions. Equity-based recruiting, standards, selection, and support require approaches that recognize the variability in applicants’ opportunities and resources and are inclusive of everyone’s needs but are particularly cognizant of the needs of the most vulnerable.

Kania and colleagues define equity as “fairness and justice achieved through systematically assessing disparities in opportunities, outcomes, and representation and redressing those disparities through targeted actions”¹². Centering equity, therefore, is an ongoing process that involves adopting a mindset that focuses on equity, creating relationships with collaborators rooted in equity, investing in resources that build equity, and utilizing practices and approaches that advance equity. Below, we describe how equity can be centered in 4 key areas of admissions: recruiting, standards, processes, and support (See Box 1).

Centering equity in recruiting means ensuring that all potential applicants have the information needed to be competitive (see Box 1). Admissions offices must proactively identify barriers to information and develop ways to overcome them. Solutions will vary by school but could include open information sessions on how to apply, invitations to the medical school, or one-on-one time where pre-health advisors share the profile of successful applicants with rejected applicants. Admissions offices should consider identifying institutions with broadly diverse student populations but few applicants to their medical schools and develop relationships with those institutions. In this way they can ensure that the institution’s students are fully informed about the process and standards, have the support they need as they prepare to apply to medical school, and feel that their application is welcomed. Devoting resources to relationship building and information sharing can help build a robust pathway for more diverse applicants who have a high likelihood of success.

The University of Kansas School of Medicine (KU-SOM) provides an example of equity-based recruiting¹³. As a state public institution whose mission is primarily focused on improving lives and communities for residents of the state of Kansas, recruiting involves visits to all colleges and universities in the state (both in-person and virtual) and targeted efforts to ensure every student in the state knows about their medical school. All state residents are invited for an interview to maximize the possibility of their acceptance. Recruiters make an array of resources available to provide information about the school targeted to all stakeholders who might influence applicant pools. This intentional effort helps ensure no single group of stakeholders becomes a potential gatekeeper.

In addition to hosting a conference for pre-med students, KU-SOM also hosts individual conferences for pre-health advisors and advisors from community colleges throughout the state. Aware that potential applicants often solicit information about medical school from physicians, the team developed a Physician Fact Sheet to ensure physicians practicing in the state who may have graduated some time ago or perhaps from a different institution, are aware of the activities at KU-SOM. Their medical students also have an Admissions Fact Sheet that they carry with them as they travel across the state for their clinical rotations. Information made available to everyone includes content relating to automatic interview criteria, holistic admission processes, how to contact the school and meet with a recruiter during virtual office hours, and an Applicant Toolkit that details important information such as application timelines, prerequisite coursework, how to apply, Medical College Admission Test (MCAT) preparation strategies, and much more.

Centering equity in admissions standards means performance metrics should be interpreted based on context, resources, opportunities, and circumstances of each applicant’s lived experience (see Box 1). Using the holistic review as originally described will help ensure all aspects of the applicant are considered in the proper context to better understand how applicants utilized their prior experiences¹⁴.

Additionally, an honest assessment of both the medical school’s mission and resources is important so that the mission-aligned students who are admitted can be adequately supported. This requires adopting an open mind with a willingness to consider all well-qualified persons who feel called or inspired to become a physician. Research has shown that nationally, students with a wide range of MCAT scores and adequate grade point averages (GPAs) make good progress from year 1 to year 2, and must pass the United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) licensing exams on their first attempt and graduate medical school within five years^15,16. We encourage using local data to identify institution-specific academic parameters to identify applicants who are prepared to study in the local medical school.

Furthermore, we encourage medical schools to avoid setting overly stringent MCAT thresholds for the purpose of expediency or image, but rather to expand their thinking about applicants who may contribute to their mission and be capable of succeeding in medical school. Admissions committees should not ask “Who is the best and brightest in the classroom?” but rather, “Does this applicant show evidence that they’ll be able to thrive in our curriculum?”

One way to create equitable standards is to develop a sliding scale of minimum readiness standards that allow for consideration of the broadest range of applicants who might contribute to a school’s mission and succeed in the curriculum. Ample evidence suggests that using MCAT scores and GPAs together, despite each measure representing a different signal of academic achievement, provides better information than using either alone^17,18. Further, national data on the USMLE Step 1 licensure exam pass rates and timely progression through medical school clearly show how using metrics in this compensatory way reveals the success of students with higher GPAs but modest MCAT scores, and vice versa, that would be missed with cutoffs that do not take this into account^16,17,18. Several medical schools, including Washington State University, University of Utah, and Rutgers Robert Wood Johnson Medical Schools currently utilize this practice^19,20,21.

Importantly, equitable standards extend far beyond academic metrics and apply to all aspects of the application. For example, it may benefit applicants at large or less-well-resourced institutions to allow letters of recommendation not just from science faculty but from a work supervisor, the director of a volunteer organization, or the teaching assistant who led a smaller discussion section. Requirements for a certain number of volunteer hours may be challenging for students who are working to support themselves and their families. Flexibility in standards is beneficial to those who come from different backgrounds and have a less common route to medical school. Likewise, some applicants may have modest GPAs and MCAT scores but demonstrate promise by having overcome large obstacles or by appearing to be aligned with a given institution’s mission and curriculum. Adopting these changes, requires admissions committees to think flexibly and to be trained in new strategies for assessment.

Centering equity in admissions processes requires review of admissions procedures and processes to ensure that historically advantaged groups do not gain unintentional benefit (see Box 1). In-group bias is a well-documented phenomenon in which people tend to favor those who resemble them and has been shown to lead to biased decision-making in business²². There is a real risk that admissions committees will tend to unconsciously use in-group bias as they make the many subjective application assessments that occur throughout the admissions process, rather than striving for increasing diversity. Providing training in unconscious bias, the impact of educational inequities on achievement, and the school’s diversity aims are excellent starting points.

Equity-based processes can take many forms and can be both visible and less visible. For example, some visible practices might include removing applicants’ photos from their application during screening to help mitigate bias based on physical appearance. Mount Sinai, for example, adopted the “Time-In” tool to pause conversation during admissions committee meetings to discuss perceived bias²³. Interviews help ensure that applicants have the social and communication skills necessary for medical education and practice and provide a balance to strict academic metrics and experiences. Making all interviews virtual could reduce inequities for economically disadvantaged and/or geographically distant applicants who may not have access to reliable transportation or funds to cover overnight travel. In preparation for interviews, all applicants should be made aware of the interview process (e.g., length, number of interviewers, types of questions, how to request disability accommodations, etc.), get instructions for accessing the virtual interview platform, have an opportunity to complete a technology check in advance of the interview, and be made aware of the AAMC interview resources available to aid preparation. This counters the advantage of having access to friends, family members, or mentors who can provide insight into the process. Additionally, including current medical students from diverse backgrounds on the admissions committee can provide valuable insight into what requirements or situations may be challenging for non-traditional applicants.

Less visible equity-based processes might include utilizing anonymous voting systems or adopting filters or scoring rubrics that consider motivation, lived experiences, degree of mission alignment, and demonstrated personal characteristics in addition to quantifying academic achievement and activities. According to the 2021 AAMC Admissions Officers Survey, approximately half of medical schools judiciously select which data, such as MCAT scores and GPA, to make available to interviewers prior to or during interviews to reduce overreliance on academic metrics⁹. Each school should adopt a practice that makes sense to them.

Centering equity in support ensures everyone gets the help they need when they need it (see Box 1). This requires a commitment across departments/programs to support students from a variety of backgrounds by providing financial, social, and educational support where it is most needed.

Research has highlighted the mismatch in economic diversity between medical students and the general public⁵. This is a problem if we want medical students who will be able to relate to patients’ diverse economic situations. At the same time, economically disadvantaged students may be reluctant to assume the significant debt incurred during a medical education. One obvious way in which medical schools can both reduce economic barriers for students and remain competitive with other schools while remaining cognizant of equity and diversity goals would be to dedicate some funding to scholarships for disadvantaged students (SDS), as opposed to only merit-based scholarships.

Once students have matriculated, it is essential to ensure that they have the support to thrive. Different students have different needs, so we recommend the practice of “targeted universalism” which ensures resources are available for everyone, but are targeted to individuals based on their specific challenges or needs. Factors such as academic preparation, resource access, mentorship, family structures and circumstances, community size, and the quality of undergraduate education are just a few of the many variables that may inform an applicant’s specific support needs as they progress through medical school.

The provision of academic enhancements should be done in such a way that students who are struggling do not feel stigmatized. Schools should find ways to normalize help-seeking behaviors by students who need academic support. Schools should use their historical data to guide allotment of resources.

Whilst equity must be embedded in every aspect of admissions to effect meaningful change, siloed solutions rarely work. The many distinct ideas need to become a program of change.

Complex systems must work together. The challenges facing medical school admissions are systems problems that require systems thinking and adaptive change. We are encouraged that the medical education community, which operates in a highly complex ecosystem where there are often vast differences between schools, is already aware of the issue of diversity and equity in admissions. However, solutions to problems must recognize the complexity of the entirety of each medical school system to maximize the collective impact.

It is important to recognize that virtually all progress begins with leadership commitment. The most successful educational programs almost always have a community of many leaders working together and building a culture in which everyone assumes a role of responsibility²⁴. Leadership successes do not consist of many random acts, but rather organized individual efforts to work together to solve a problem. The Morehouse School of Medicine is one example of a medical education program that embodies distributed leadership with its supportive, relationship-focused environment, family atmosphere, high degree of faculty-student engagement, and community in which the learners assume leadership roles to be “agents of positive social change”²⁵.

It is also necessary to adopt data-informed practices that include continued review and assessment, as a lack of evaluation will ensure unproven and potentially ineffective practices are continued. Evidence-based identification of problems, proposing one or more solutions based on local data and existing research, implementing those solutions and gathering data and investigating changes are required. Simply put, if an admissions process is intended to help meet the institution’s mission and goals, then outcomes should come closer at each phase to achieve the desired goals. Instances in which there is little movement or, worse, further divergence, create an opportunity to understand why, try something different, and see what happens. Therefore, the iterative practice of thinking like scientists will help foster and sustain a culture of continuous improvement. Everyone, regardless of their role or comfort working with data, is capable of thinking like a scientist to rely on data-informed decisions that are transparent and equitable.

History has shown that one-size-fits-all assessments of applicants do not work. The 2023 SCOTUS decision confirmed there remains value in considering each applicant’s lived experience to help contextualize each applicant. However, holistic review in and of itself is not enough, it must be combined with equitable admissions standards and processes and targeted universal support for all learners. Despite virtually all medical schools using elements of holistic review, relatively little progress has been made in the United States in diversifying the workforce and achieving equitable health outcomes. We argue that to effect real and enduring change, medical schools must embed equity into every aspect of admissions and support of learners. Centering equity requires a collective impact community to help us learn together and accelerate the impact of solutions and change, and efforts at each medical school to develop and implement equitable strategies that make sense given their mission, goals, priorities and resources.

Although we focus on admissions into medical schools in the United States, some recommendations can be applied globally and to other health professions. The 2013 World Health Organization guidelines for transforming and scaling up health professions’ education recognized severe health workforce shortages worldwide and gave recommendations for alleviating this deficit²⁶. One key recommendation was for the broader health professions education enterprise to consider using targeted admissions policies in order to improve the socio-economic, ethnic, and geographical diversity of students, as presented here.