At an assembly during my first week of medical school, one of the institution’s venerable deans took to the podium to announce that our class marked a turning point in the school’s history: nearly half of us were female.
My classmates and I were unimpressed.
For while our genders might have been mixed, it hadn’t taken us long to realize that on paper we were remarkably alike. We had similar college majors, grade point averages and scores on the standardized Medical College Admissions Test, or MCAT. Most of us came from relatively comfortable backgrounds, spent summers working in a lab and had parents heavily vested in our education. Two of us, while not related, even shared a relatively uncommon last name.
The few classmates from underrepresented groups in medicine — African-Americans, Latinos and Native Americans — stood out.
“This is medical school,” a classmate remarked. “It’s not about who you are. It’s about how well you do in science and the MCATs.”
That perspective has long been assumed to be a guiding principle of medical education. But now, as the country’s universities and courts are struggling once again to define diversity and admissions policies, two perspective pieces in The New England Journal of Medicine reveal that admissions policies have been quietly but radically changing in a handful of medical schools. And those changes have yielded surprisingly successful results.
Each year, on average, medical school admissions committees sift throughsome 4,500 applications for each entering class of 100 to 200 or more students. The first cut is most fierce; of those thousands of applicants, only a few hundred are invited for an interview. From there, roughly one in every four of those interviewed will be accepted.
Medical schools have traditionally relied on undergraduate science grades and the MCAT to decide which applicants to interview. They based this approach in part on numerous studies that found good correlationsbetween science G.P.A. and MCAT scores and subsequent medical school performance.
But more recent studies have also revealed that MCAT scores are significantly influenced by a student’s race, gender and socioeconomic background. Observers have noted, too, that a large and lucrative industry has developed around MCAT preparation; and students who could not afford the substantial tuition or time required by such prep courses were finding themselves at a disadvantage.
In response, a few medical schools and the Association of American Medical Colleges began to experiment with a different approach to admissions. Instead of using grades and MCAT scores as cut-off points to whittle down the initial applicant pool, they began assessing those numbers in the context of life experiences, socioeconomic status, cultural and ethnic background, gender identity and the medical school’s particular mission, be it to produce research scientists, compassionate clinicians or both.
But unlike traditional medical schools that might have been reserving such “holistic review” for the few candidates fortunate enough to be interviewed, these schools went one step further; they engaged in holistic review from the get-go, applying it to every submitted application.
The results have been both uplifting and unexpected. Since Boston University School of Medicine began incorporating holistic review in all phases of its admissions process five years ago, faculty members have noted that students appear to be more collegial, supportive of one another, open to new ideas and perspectives and engaged in community activities. They also have turned out to be as prepared as previous students, with no significant differences in average MCAT scores and college grades.
And, despite a lack of quotas or caps, students from groups underrepresented in medicine have nearly doubled, to 20 percent.
“This is not your father’s Oldsmobile of a medical school class anymore,” said Dr. Robert A. Witzburg, co-author of one of the articles and the associate dean and director of admissions at Boston University School of Medicine.
The Icahn School of Medicine at Mount Sinai has been engaged in an even more radical version of holistic review. Starting in 1987, they began offering an “early assurance” program to a select few college sophomores. These students did not have to take the MCATs and were guaranteed a slot in the medical school if they continued to study humanities or social sciences and maintained a 3.5 grade point average, instead of pursuing the traditional premedical science program.
Two years ago, the school published a study detailing the results of the program – students performed as well as their more traditional counterparts and were more likely to pursue fields like primary care and psychiatry. Based on the successful outcomes, the school now plans to expand the program. Beginning this fall, they will invite college sophomores from all majors to apply and will reserve half the slots of each medical school class for these non-traditional premedical students.
“It’s time for us to take some risks,” said Dr. David Muller, author of one of The New England Journal of Medicine articles and dean for medical education at Mount Sinai. “We need to push the limits on what we’ve been complacent about for too long.”
Still, there are significant challenges for medical schools in adopting such holistic approaches. Medical schools are under growing pressure to sustain or even increase their standing in national surveys; and administrators may worry that paying less attention to MCAT scores, which are often used to calculate school rankings, could hurt their institution.
A holistic approach to admissions also requires a lot more work than simply looking at test scores. Boston University’s medical school admissions office, for example, processes roughly 400,000 pages of documentation each year; and many institutions may find the additional work required too labor-intensive.
“You could sort every female applicant in Wyoming by MCAT score with three keystrokes,” said Dr. Henry M. Sondheimer, co-author with Dr. Witzburg of one of the articles and the senior director of Medical Education Projects at the Association of American Medical Colleges. “It takes more time to get to know the students.
Nevertheless, 43 of the nation’s 141 medical schools have already expressed interest in adopting some form of the holistic review approach, enrolling in a workshop offered by the A.A.M.C. And over the next few years, the A.A.M.C. will track how students accepted under this approach fare and assess how they do in medical school, during training and, most importantly, in practice.
“No one is saying that skills and inclination in science is not important,” Dr. Witzburg said. “But in this rapidly evolving and diverse society, they are insufficient.”
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