In the not-too-distant past I was asked to serve on the admission committee of an allopathic (MD-granting) medical school here in the United States. I won’t get into the details, but suffice to say I am a physician who has been through the ringer of 9 years in training, so I gladly accepted the opportunity to peek behind the curtain.
Before I get any further in, I need to issue a disclaimer. My observations and opinions regarding medical school admissions are just those: anecdotal observations and personal opinions. They represent experience on one committee in one medical school over a limited period of time. No doubt other committees operate very differently, and every committee member across the country brings a unique perspective. Generalize with caution and care.
The push for
If one reads the literature related to medical school admissions and outcomes, a very clear bit of dogma emerges: we need more minorities in medicine. The technical term is URM (underrepresented in medicine), which primarily encompasses those who identify as black, hispanic, and/or Native American. The case for trying to get more of them into medical school is a compelling one; they are more likely than non-URMs to practice in medically underserved communities, and generally form stronger bonds with patients of the same racial/ethnic background, which in turn leads to more positive therapeutic relationships and better medical outcomes. And that is to say nothing of the positive effects that a diverse student body has on the learning environment in medical school, well before anyone steps into independent practice.
Fortunately, most of the committee members I worked with got this message and were on board. Even if they did not, however, we would be under strict scrutiny with regards to URM admissions because of accreditation. The accrediting body for allopathic medical school in the US is the LCME (Liaison Committee on Medical Education). For years now the LCME has been a huge proponent of diversity in medical education. Ostensibly schools can define their own criteria for diversity (black, hispanic, Native American, veteran, first generation, LGBTQ, etc.). But there seemed an omnipresent if unwritten requirement that black and, to a lesser extent, hispanic, be included in any acceptable diversity plan.
The need for more blacks in medical school is actually quite stark. In the most recent application cycle a mere 514 black men matriculated into allopathic medical schools in the US. This number is lower in absolute terms than in the late 1970’s. It’s pathetic. Everyone should agree that the situation is unacceptable and must be remedied.
The headwinds against
When considering URM applicants for admission to medical school, one quickly runs into a difficult reality: there aren’t very many of them in the pool, and many of the ones that do exist have worrisome academic records. The AAMC (Association for American Medical Colleges) publishes regular statistical profiles of medical school applicants and matriculants broken down by a variety of factors. The upshot is this: finding a URM applicant with good numbers is, from an admissions standpoint, not unlike finding the holy grail.
This brings me to the typical deliberations over a medical school applicant that I have observed. In general terms, when an applicant is brought up for discussion the fundamental question before the committee is “why should we admit the person?” When a URM is brought forward, however, the question fundamental shifts to become “why shouldn’t we admit this person?”
In and of itself, this difference of framing is not a problem, except for one small issue: the categorization of URMs is deeply flawed. An African American man who grows up in poverty and claws his way to a bachelors degree is counted the same as the child of a wealthy Nigerian diplomat: black. Likewise, the daughter of Mexican immigrants who work the fields is counted the same as someone whose Argentinian physician parents came to the country to practice in lucrative fields: hispanic.
Not surprisingly, the URM children of affluence were almost always admitted, and those that matriculated became part of the diversity shield that protected us from our accreditors. Cells on a spreadsheet, to be sure, but nonetheless concrete evidence that we were on the diversity train. Superficially, at least.
The evolving landscape
Unless you are applying to medical schools in Texas, allopathic medical schools in the US accept applications though a system called AMCAS (American Medical College Application Service). AMCAS provides a centralized, singular application platform that streamlined and simplified the prior system of every medical school having a unique (paper) application.
AMCAS collects quite a bit of data on its applicants, and in the last few years they have added a new factor for medical school admission committees to consider: the economic-occupational (EO) factor. While imperfect, the EO factor is determined by the current jobs and highest educational levels obtained by an applicant’s parents. Someone with EO-1 is considered of lowest socioeconomic background, someone with EO-2 is in the next-to-lowest category. Above that there is no stratification.
The development of the EO factor came in conjunction with the publication of a AAMC paper on effective practices in using socioeconomic status (SES) in admissions. There seems to be an emerging notion that the SES of one’s youth should be a significant factor in this process. On some level it has been, and the committee proceedings I have been involved in have demonstrated a sensitivity to “distance traveled,” although it is seemingly harder to measure the diversity of a class by poverty-gone-by than skin color.
Why the fuck?
My reflections on this election, and a lot of what I have read since November 8, involve a lot of thought about two groups I will term the historically marginalized (i.e. persons of color) and the presently ignored (i.e. poor rural Americans). Both groups have been shit on, to varying extents and in varying time periods, but they have a common element: socioeconomics. It cuts like a knife from row houses in east Baltimore to shotgun shacks in west Kentucky.
When it comes to choosing future generations of physicians, real reform, real improvement will have to happen much earlier than admissions. The URM applicants who arrive with terrible numbers often aren’t lacking in intelligence, they have been systematically let down by years of substandard educational practices. Alas, medical school is usually not the place to remediate such deficiencies. We take chances, to be sure, but miracles are few and far between.
I hope that SES takes a bigger role in coming years; as I am typing this I am wondering if there is data on rural applicants that shows a similar proclivity for rural practice, another broadly underserved demographic. I hope that undergraduate institutions can continue their push to shepherd low SES students, URM and non-URM alike, through the process of finishing college and being prepared for post-graduate education. I hope that the inroads made by LGBTQ and others will be further deepened and widened in coming years.
One can dream, I suppose.