For thousands of individuals every year, receiving an acceptance letter from a U.S. medical school is a monumental occasion. The culmination of years of hard work and sacrifice. It is an acknowledgment of academic prowess and ability. This is an indication that years of hard work and dedication have paid off and that, since being selected, an individual possesses unique talents and abilities, allowing them to enter an esoteric realm of education training. Or so it ostensibly seems to be. On the contrary, recent data indicates that medical school admissions have become more and more exclusionary.
Despite decades of diversity and inclusion initiatives, U.S. medical schools continue to be elitist institutions with very few minorities. A majority of diversity initiatives have focused on racial/ethnic groups that are underrepresented in medicine. However, this may have further prevented diversity in the long run. The real problem, some may argue, is not race/ethnic diversity. Rather, socioeconomic status (which at times can parallel race) is the real issue. For example, recent data indicate that acceptance rates for individuals who are underrepresented in medicine (URiM) have increased, and these individuals have favorable odds when controlling for GPA and MCAT scores. However, these positive associations are not seen for low-income or first-generation applicants. This raises the question of whether diversity initiatives are impacting the individuals they originally intended to. At its core, diversity initiatives should increase the probability of the disenfranchised to gain acceptance. In essence, it should level the playing field and remove barriers to entry. However, if individuals who benefit from these initiatives continue to come from high-income families, it is reasonable to assume that these applicants would have been accepted in lieu of any diversity initiatives. The data seems to support this notion.
Attending medical school in the U.S. continues to be a matter of socioeconomic status and less so on merit-based factors. For example, from 2014-2019, applicants to MD programs in the US who had a family income of less than $50,000 were half as likely to be accepted as applicants reporting an income of $200,000 or more. Moreso, the likelihood of being accepted into an MD program increased incrementally by income. In essence, socioeconomic diversity has decreased over time.
Some argue that current organizational structures, such as medical schools, serve to legitimize and entrench racial inequities. The process of medical training in the U.S. is a structured pipeline designed to exclude members of low socioeconomic status. Medical admissions rely heavily on “objective measures” such as the MCAT, GPA, and other test scores. Students who have the financial means are able to obtain private tutors and pay for resources that are considered the “gold standard” for preparation for these exams. In addition, test preparation is becoming increasingly expensive, with resources such as UWorld easily costing an applicant hundreds of thousands of dollars. Taking a significant amount of time off to dedicate to studying for an exam and foregoing work is not an option for many individuals who don’t have the financial means to do so. Lower mean MCAT scores are sometimes a result of socioeconomic disadvantages for certain groups. Institutions justify the use of MCAT scores as they have predictive value for medical school success, namely licensure examinations. This further reinforces the status quo of utilizing a seemingly objective measure (USMLE exams) to practice fair admission policies.
School reputation and merit-based scholarships reward the use of MCAT scores, and institutions maximize their weight in admissions despite these practices being associated with lower diversity. The number of applicants to medical schools continues to grow each year, and admission offices have relied on computer-generated MCAT score cutoffs as a screening measure to qualify applicants. In addition, many schools have continued to use legacy as a factor in admissions, perpetuating nepotism and reinforcing entrenched racial inequities.
Faculty that attempt to alter the trajectory of admissions policies to reflect more diversity are often met with staunch resistance. Altering institutional policy is incredibly difficult especially when there have been generations of precedent already established. Organizational factors play a significant role in which admissions policies are implemented and how rapidly diversity initiatives can be implemented. Frequent turnover, changing of priorities, and performative acts without institutional change in policy or resources are some of the main factors found to be preventing the increase of diversity.
Medical school admissions, despite being touted as a meritocracy, involve a significant amount of privilege. Medical schools should review their admission processes and consider socioeconomic status, as individuals from low socioeconomic groups have historically been excluded. Unjust measures such as GPA and MCAT exclude a large pool of applicants or potential applicants, nullifying the very intention of diversity initiatives.
Ravinder S. Chale is a medical student.
