Revolutionizing Health Professions Admissions to Achieve an Inclusive Workforce

Traditional Metrics

The primary medical school application traditionally prioritizes 2 quantitative metrics: Medical College Admissions Test (MCAT) scores and undergraduate grade point average (GPA). Although admission committee members often view these metrics as a proxy for academic readiness, it is widely recognized that these metrics often bely privilege rather than aptitude and cannot account for structural barriers impacting an applicant’s access to health professions education.⁶ MCAT scores do not reliably predict future performance in medical school or residency,^7,8 yet are still widely used in medical school admissions. Other health professions schools use similar quantitative metrics, including the Pharmacy College Admission Test, Dental Admission Test, Graduate Record Examination, and the new Physician Assistant-College Admission Test. There has been increasing momentum, however, toward implementing more holistic admissions and broadening the metrics used to evaluate health professions schools’ applicants.

One way to mitigate this disparity is to implement a threshold or minimum “passing” MCAT score rather than using a continuous or scaled score, which implies that higher numbers equate to greater aptitude. Rather than a national pass/fail threshold,⁹ many experts suggest that each school evaluate its own support system and data from current and prior students to determine a threshold that will enable a given student to succeed within the curriculum.⁶

Alternative Metrics

Waiving standardized test scores in the admissions process has been a successful tool for including traditionally marginalized students. In the past decade, many graduate programs have made the Graduate Record Examination (GRE) score optional, reducing the barrier to admission for low-income students of color.¹⁰ To diversify the physician workforce, admissions committees should consider making the MCAT optional or pass-fail, and placing greater emphasis on other criteria.¹¹ Schools using holistic review are more likely to examine other non-academic criteria such as socioeconomic status,¹² experience working with disadvantaged populations, and mission alignment (eg, focus on underserved rural or urban communities).^13,14 Some physician assistant programs examine measures of humanistic and collaborative skills including applicants’ experience as patient educators, community organizers, or working at community-based organizations.¹⁵ Admissions processes should allow applicants to describe their background and experiences that potentially align with the institution’s mission, as well as the opportunity to explain life circumstances that may have adversely affected their academic trajectory.¹⁵ De-prioritizing GPA and standardized exam scores, while prioritizing other metrics is crucial for diversifying the workforce.

Examples of Alternative Admissions Metrics

The UC Davis School of Medicine utilizes a locally developed socioeconomic disadvantage (SED) score alongside MCAT and GPA in the admissions process. The SED score incorporates multiple indicators of disadvantage from the medical school common application, such as parental income and education, receipt of federal or state financial assistance, and living in an underserved area (Table 1).^2,16 Implementation of the SED score resulted in a wider matriculant MCAT and GPA ranges while increasing racial-ethnic and economic diversity among matriculants. AT Still University-Arizona School of Dentistry and Oral Health (ATSU-ASDOH) considers community service and outreach hours as its top admission metric, while GPA is considered a secondary metric (Table 1).

Admission Committee: Who Is at the Table?

Determining the makeup of the admission committee is a critical intervention for bolstering diversity in health professions students. A 2000 study across 85 US medical schools found that only 16% of committee members were from underrepresented groups.²⁰ While we hope that representation has increased, little is known about the composition of admissions committees in recent years. Each institution should consider the following questions regarding admissions committees: Who is at the table? Who has been included? Who has been excluded? Answers to these questions should inform recruitment of new members to increase the diversity of perspectives and backgrounds, particularly those from underrepresented groups. Students should be included as full voting members of admissions committees as they offer a unique and important viewpoint. Students also feel ownership and autonomy over helping shape their future learning community.²¹ Finally, it is important to ensure the composition of the admissions committee reflects the mission of the institution.²² The institutional mission should include service to the local community and authentic community partnership.

Training for Admissions Committee Members

Once a diverse representative committee is composed, its members must receive adequate antibias and antiracism training. At the Washington State University Elson S. Floyd School of Medicine (WSU), admission committee members are trained extensively to look for mission-aligned applicants; applicant metrics are masked shortly after the admissions process begins. Bias must be minimized throughout the process. In a study at Ohio State where admissions committee members took the Black-White implicit association test (IAT),²³ all groups displayed a preference for White people. However, in the subsequent year’s admission cycle, 48% reported being conscious of their IAT results and 21% said their results impacted their interview and admissions decisions, producing “one of the most diverse (entering classes) in the Ohio State University College of Medicine’s history.”²³

The Admission Process and Exclusionary Practices

Applicants with physical/sensory, cognitive/learning, or mental health disabilities encounter many barriers in the admissions process including: the requirement to disclose disability status to obtain equitable access, inflexible technical standards, and a lack of mentors familiar with students with disabilities.²⁴ To make health professions education more accessible to such students, all faculty and students should receive anti-ableist training; and admission processes should be re-examined for potential exclusionary practices.²⁴ Technical standards (eg, observation, motor function) frequently exclude students with disabilities. Entrance exams can be a barrier for individuals with disabilities and obtaining the required documentation for accommodations can be quite costly. Other admission requirements such as shadowing can be extremely difficult to obtain for deaf or hard-of-hearing applicants. Every health profession training school should incorporate disability into their diversity and inclusion efforts.

Exemplars of Community Partnerships to Fulfill Social Mission

An exemplary community partnership comes from the University of Cincinnati, which created a Community Advisory Board (CAB) to engage community stakeholders in health equity and workforce development.²⁶ The CAB spurred development of a Health Workforce Diversity Workgroup, which implemented a series of programs to engage and promote recruitment of health professional trainees from the community.²¹ Temple University Lewis Katz School of Medicine invited Philadelphia community members to join its admission committee as interviewers.²⁷ Community members can assess prospective students’ readiness to work with diverse populations, and strengthen ties between the institution and the community. Community interviewers residing or working in the neighborhood were paid for their time and expertise. Ninety percent of interviewees reported that community interviewers helped them understand the community and the medical school’s values.²⁷ Therefore, inclusion of community members benefits all stakeholders, including the community, the institution, and prospective students.

Health professions schools also partner with communities to address workforce needs.²⁸ Over the past decade, UC Davis School of Medicine has intentionally developed community-based training pathways that address the regional health workforce shortages, with many graduates going on to pursue primary care training and serve those communities. AT Still University-School of Dentistry and Oral Health developed a Hometown Scholars’ pathway for aspiring dentists, physicians, and physician assistants.²³ A Hometown Scholar endorsement allows community health centers to highlight and endorse an applicant’s experience in a community health center and intention to become a community-minded clinician.²⁹ Another exemplar is the Elson S. Floyd College of Medicine at Washington State University (WSU), which recruits students with ties to Washington State to train within their communities, increasing the probability they will become a part of the Washington State health workforce. Its mission is “to solve problems in challenging health care environments across the state of Washington” (Table 3).

Pre-Matriculation

Attrition from the health professional career pathway continues well beyond matriculation. Our goal cannot be simply to admit students from underrepresented groups, but to support them to succeed throughout the entire educational continuum. Racial and ethnic minority students, as well as low-income students, are more likely to take time off during medical training³⁰ or leave medical school altogether.^31,32 Health professional institutions can begin supporting students during the admissions process by creating environments in which applicants feel empowered and like they belong. At the interview stage, WSU positively affirms that interviewees have made it to this point because they are qualified and able to succeed in the profession. This affirmation reduces the salience of race or ethnicity and helps create an identity safe interview process³³ which may allow students to better showcase their skills via reduction of stereotype threat.³⁴

Holistic Support

Institutions must regularly collect and assess data on student experience, including unmet needs and strategies for support. Lack of basic needs such as housing and food security negatively affect academic progress, particularly for underrepresented and low-income students.^35,36 The Native American Nursing Education Center at South Dakota State University³⁷ emphasizes the critical importance of providing tangible wrap-around support including scholarships, financial education, and transportation. Students from underrepresented groups have higher anticipated debt, particularly Black or African American medical students.³⁸ The Vanderbilt School of Nursing discussed the importance of mentorship by faculty members from similar backgrounds and peer support to aid underrepresented students’ academic success and feelings of belonging. For students with disabilities, feelings of belonging are tied to student services and available accommodations; 50% of students with disabilities do not request for accommodations.³⁹ In addition to an infrastructure to support students with disabilities within health professional schools,²⁴ there should be a clear and readily available process for requesting accommodations without stigma.³⁹

The learning environment is an area of unmet need for students from minoritized groups. In a national cohort study, Black, Asian, Multiracial, and female medical students were most likely to have experienced microaggressions at least weekly.⁴⁰ Such students were less likely to recommend their medical school, less likely to want to stay at their current institution for residency training, and more likely to leave medical school altogether.^40,41 To diversify the health workforce, institutions must examine their own culture and commit to making training challenging but not traumatizing. Institutions should use local data on the student experience to change policies and/or personnel to better support students. If institutions collect such data and do not use it to improve the environment, students may lose trust in the program.