Abstract
The impact of the Supreme Court of the United States ruling against race-conscious admissions extends beyond college admissions to professional schools. Based partially on the idea that enough time had elapsed for achievement of the stated goals of affirmative action, the court ruled race-conscious admissions are unconstitutional under the 14th Amendment’s Equal Protection Clause. The ruling left a crack in the door to higher education, however, allowing students to write an essay showing how race or ethnicity affected their lives. But without guidelines or a standardized approach, admissions committee members’ background, personal experiences, and biases could influence evaluations.
Historically, Black Indigenous People of Color (BIPOC) have experienced residential segregation. Thus, they are products of poorly funded and understaffed K-12 schools. Grade point average and standardized tests scores are heavily weighted during the admissions process in higher education; however, these metrics largely reflect the attributes of K-12 schools and access to advanced placement and science, technology, engineering, math, and medicine (STEMM) courses. These courses are often lacking in schools with predominantly BIPOC students. We must continue to develop and support K-16 STEMM programs.
Higher education institutions must respond to the Supreme Court ruling. Recruitment and retention strategies should encourage, guide, and support students who pursue health care careers. Enhanced admissions processes must include a standardized, unbiased approach in assessing personal essays and the lived experience. Admissions committees should complete implicit bias and cultural humility training. Support and allocation of funds must be provided to maintain training. Safeguards must ensure applicant and institutional legal compliance.
- race conscious admission
- biases
- K-16 stem-based programs
- personal essays
- lived experiences
- cultural humility
INTRODUCTION
During its 2023 session, the Supreme Court of the United States (SCOTUS) decided in a 6 to 3 vote against the use of race-conscious admissions in higher education.1 In the court’s majority opinion, Chief Justice John G. Roberts, Jr wrote,
Nothing in this opinion should be construed as prohibiting universities from considering an applicant’s discussion of how race affected his or her life, be it through discrimination, inspiration, or otherwise.1,2
He also wrote,
A benefit to a student who overcame racial discrimination, for example, must be tied to that student’s courage and determination. Or a benefit to a student whose heritage or culture motivated him or her to assume a leadership role or attain a particular goal must be tied to that student’s unique ability to contribute to the university. In other words, the student must be treated based on his or her experiences as an individual — not on the basis of race.1,2
The primary fallacy with his statement is the impossibility of separating race from identity and personal and professional development. In a social structure historically founded along the binary of race—White vs non-White—it is extremely difficult to exclude the influence of race in shaping and dictating the environment and our personal and professional development.3 We are all individuals whose lives have been shaped and directed by multiple stressors and barriers in the built environment, including the intergenerational effects of race and racism.4-6
In a society in which the educational, economic, political, and health care structures were founded and evolved during 400 years of slavery, racial segregation, discrimination, and subordination, lingering effects of race and racism are ever-present factors in shaping and dictating the lives of Black, Indigenous, People of Color (BIPOC) and White people.4-6 Researchers have applied the term “toxic stress” to the effects of persistent adverse life circumstances—such as racism, discrimination, and poverty—which may influence genetic predispositions that affect an individual’s emerging brain architecture and long-term health. Toxic stress can have a pronounced effect on those areas of the developing fetal brain that primarily function in cognition, linguistics, behavioral responses, and ability to respond to stressful situations. Toxic stressors such as racism, discrimination, segregation, and poverty play a major role in forming the built environment (housing, public schools, grocery stores, place of employment, health care access) of BIPOC. Due to a lack of economic and social mobility many BIPOC find themselves stuck in toxic and unsupportive environments created by years of segregation (red lining), discrimination, and racism. Generation after generation of excessive activation of stress response systems in early childhood can play an important causal role in the intergenerational transmission of poor health and lay the groundwork for chronic, stress-related diseases (hypertension, diabetes, cardiovascular disease, diabetes, depression) later in life.7,8
Evaluation and Impact of Personal Essays in Admissions
Although the court ruled race-conscious admissions are unconstitutional under the 14th Amendment’s Equal Protection Clause,1 the ruling left a crack in the door. In a personal essay, students can discuss how race or ethnicity affected their life. That discussion must be concretely tied to a quality of character or unique ability that the applicant can contribute to the university.1
However, the ability to discuss how race has affected one’s life and how that can be concretely tied to a quality of character or unique ability that the applicant can contribute to the university may be difficult for high school students. The average age of a first-year college student is 17 or 18 years.9 This coincides with the formal operational stage of Piaget’s theory of cognitive development10,11 beginning at approximately age 11-12 years and extending into adulthood. This stage is defined by the emergence of higher executive functions such as abstract thoughts, deductive reasoning, logical thought, and problem solving. In many cases, cognitive development and maturation continue into early adulthood. Absence of prior institutional knowledge may further hinder some students from composing a clear, concise personal essay that identifies and articulates unique personal characteristics that may contribute to the success of an institution.10,11 Thus, it may be even harder for educationally disadvantaged BIPOC students from underfunded, under resourced, and understaffed schools to compose a legal and compelling statement.
One Year After the End of Race-Conscious Admissions
Although it has been only 1 year since the Supreme Court ruling, a recent publication examined the effect of the Supreme Court decision.12 It consists of a large database examining 6 million applications over a 5-year period, starting in 2019-2020. Findings show no substantial differences in the rates at which students, overall, are choosing to write about their racial/ethnic identity in their personal essay. The only exception was a subset of higher-achieving underrepresented minority (URM) applicants who showed a trend toward discussing their racial/ethnic identity slightly more often than comparable non-URM students. This may be due to multiple factors, including lack of awareness and understanding of how to approach the court’s guidelines, inability to articulate the role of race or ethnicity in their life course based on the guidelines of the court, or fear of legal infractions that may jeopardize their application. Several elite universities have experienced significant demographics shifts. MIT, Amherst College, and Tufts University experienced a steep drop in enrollment of African American and Hispanic or Latine students. Compared with the class of 2027, MIT’s newest class saw a decrease in African American/Black (15% to 5%), and Latine (16% to 11%) student enrollment. Amherst and Tufts saw Black student enrollment decrease from 11% to 3% and 7.3% to 4.7%, respectively.13
Medical School Admissions
With respect to the medical school admissions process and committee, there is no standardized or normalized data specific to race and ethnicity involved in evaluating the personal essay. Without guidelines or available comparisons, evaluations and consideration of personal statements and the committee’s decisions may become influenced by the background, personal experiences, and biases of each admissions committee member.14-22 Even though students will have the opportunity to describe how race and ethnicity had a profound effect on their personal and educational development and ultimate life course, there is little guarantee admissions committees or individual committee members will have the much-needed insight and time to adequately review, interpret, and factor in the life stories of students as it relates to race or ethnicity.
In 2022-2023, 150 allopathic medical schools received 990,790 applications from 55,188 applicants. This resulted in 22,712 matriculants.23 The task of reviewing and ranking applicants is time consuming and requires a well-informed, focused, organized, and intentional effort on the part of individual committee members to remain thorough, efficient, objective, and unbiased. Because we all have biases (explicit and implicit) that, in many cases, surface during times of stress or time-sensitive activities, there is some degree of likelihood that individual committee members, either due to a lack of awareness, training, or time constraints, will consciously or unconsciously dismiss or fail to adequately interpret or consider salient components of a student’s personal essay, as it relates to the impact of race and racism on their personal and professional development.14-17 How to review and consider race as part of a personal statement and a significant factor in the life course of students is not yet well-defined.
In many institutions, the admissions committee is composed primarily of faculty. Many have limited exposure to formal training surrounding cultural humility, implicit bias, structural racism, stereotyping, stereotype threat, or resilience.24-26
This leaves open the question of how one may interpret the content of a personal statement, as it relates to economic and educational hardships and barriers resulting from race and racism that may not be so easily recognized and fully appreciated. Lack of a sense of the connection between structural racism as a definitive barrier in the economic and educational progression of BIPOC could negatively skew comprehension and objectivity. Thus, assessment of personal statements may be inadequate and, in some cases, unfair.
Historically, BIPOC have been residentially segregated and attended poorly funded and under-staffed K-12 schools, which lack prerequisite advanced placement (AP) and science, technology, engineering, math and medicine (STEMM) courses that are crucial in preparing students for undergraduate studies leading to a career in medicine. In K-12 schools with predominantly Black student populations, total enrollment is almost 3 times higher than in school districts with mostly White students.27 The result is high student:teacher ratios in under-resourced and, in many cases, segregated schools. As products of segregation and structural racism, BIPOC students play a continuous game of catch-up that extends into higher education and medical school. Admissions committees must be aware of and consider the lived experience as well as the educational and socioeconomic background of each student. In many cases, this may not be expressed in a personal statement, or it may be undervalued or underappreciated.
Metrics such a grade point average (GPA) and scores on standardized tests that are heavily weighted during the admissions process are in large part the product of the K-12 systems and a direct reflection of the lack of access to important educational opportunities that many BIPOC experience as they navigate the primary and secondary educational system.28,29 Not all stories are the same. The admissions process must be altered to allow individual committee members and the entire committee to be aware of and consider each story in the context of the historical impact of race on the K-16 educational systems and the built environment.
Time-Limited Race Conscious Admissions
The Court agreed there is value and benefit in diversity but felt the projected benefits were not objective or measurable and that enough time had elapsed for achievement of the stated goals of affirmative action. This may have been primarily based on the majority opinion delivered by Justice Sandra Day O’Conner in the 2003 Grutter vs University of Michigan case upholding the use of race as one of multiple factors in race-conscious admissions.30 As stated by Justice O’Conner:
It has been 25 years since Justice Powell first approved the use of race to further an interest in student body diversity in the context of public higher education. Since that time, the number of minority applicants with high grades and test scores has indeed increased. We expect that 25 years from now, the use of racial preferences will no longer be necessary to further the interest approved today.2,30
She also stated:
It would be a sad day indeed, were America to become a quota-ridden society, with each identifiable minority assigned proportional representation in every desirable walk of life. But that is not the rationale for programs of preferential treatment; the acid test of their justification will be their efficacy in eliminating the need for any racial or ethnic preferences at all.30
At question in the Harvard and University of North Carolina cases is not elapsed time but continued need. Part of the 2003 ruling was the need for periodic evaluations and self-reflection, to determine overall progression of racial and ethnic equality and the continued need for race-conscious admission. Although Justice O’Conner’s statement is subject to a wide range of interpretations, given her position on the Grutter case and her past support of diversity, the most likely intent of the statement is not to provide a concrete cutoff of 25 years but rather to emphasize the need for more time to move beyond the level of discrimination and racism of 2003. In the context of higher education, durational requirements can be met by sunset provisions in race-conscious admissions policies and periodic reviews to determine whether racial preferences are still necessary to achieve student body diversity.30 Based on current Association of American Medical Colleges (AAMC) enrollment data, students from minority and underrepresented populations make up 23.6% of enrollees in medicine even though minority and underrepresented groups make up 34.6% of the US population.31,32 Although success of an admissions process may not be measured by reaching population parity or a preset quota, this large enrollment gap falls far short of achieving a level of diversity that is associated with a reduction in reported incidents of discrimination, bias, stereotyping, and exclusion of minority students.33,34
What’s Next?
Institutions can use and build on the court’s opinion. However, it will take an aggressive, organized, and intentional national effort at improving and/or altering the admission process. This includes writing personal essays that convincingly highlight and share a student’s life experiences. Efforts must ensure that a student’s personal statement will be read, objectively measured, and considered in the admissions process. This includes formal selection, training, support, and promotion of admissions committee members.24,29 It is up to the academic community to make this adjustment. If we fail, we agree with Justice Sotomayor that the current SCOTUS ruling is superficial and is only putting “lipstick on a pig.”
Recommendations
Maintain Holistic Admissions in Medical Schools
Holistic admissions must remain at the forefront of the selection process. To help standardize holistic admissions processes, the AAMC created the Experiences-Attributes-Metrics model, which is widely used by medical schools. This model supports schools’ efforts to identify, recruit, and retain students with life experiences and attributes such as resilience, integrity, adaptability, persistence, motivation, and empathy that may enhance their ability to provide care to minority and underserved communities.34 This evidence-based approach helps the AAMC, and medical schools, fulfill their mission to grow a diverse and culturally prepared health care workforce. Further, it helps ensure every applicant receives individualized consideration.34,35
Increased Support for K-16 STEMM-Based Academic Enrichment Programs
Over several decades, STEMM-based academic enrichment programs have effectively assisted underrepresented and disadvantaged students by providing them with role modeling, mentoring, coaching, networking, shadowing, and exposure to health care career paths. All serve to increase student confidence and social capital and help them overcome academic deficits that in many cases begin before kindergarten.36,37 Prominent features of these programs must be programming and activities to increase awareness and educate students on the current state of race-conscious admission and provide support and guidance in writing personal statements. Programs should include instructions and activities focused on writing skills and coaching in writing that demonstrates the influence and impact of race on the life course, while staying within legal bounds. This should also include small group sessions facilitated by health care providers from underrepresented and marginalized groups. Sessions should focus on career paths and the perceived impact of race, ethnicity, gender, socioeconomic, and disability status on personal and professional development as well as the students’ ultimate life course.
Provide Questions in the Application That Prompt Applicants to Express the Impact of Race and Racism on Their Life Course
We must develop and include questions in the application process that prompt students to capture their experience of overcoming barriers due to individual or institutional discrimination based on race, ethnicity, religion, gender, sexual identity, or disability status.38-41 Several undergraduate institutions, including Indiana University, Yale, Harvard, Columbia, and the University of West Virginia, have done so. Indiana University at Bloomington asks the required question: “If you encountered any unusual circumstances, challenges, or obstacles in pursuit of your education, share those experiences and how you overcame them.”38 One of 5 short-answer questions posed by Harvard is: “Harvard has long recognized the importance of enrolling a diverse student body. How will the life experiences that shape who you are today enable you to contribute to Harvard?”38
Selection and Training of Admissions Committee Members
Serving on the admissions committee should not be voluntary or assigned but a formal selection process.24,29 Selection of admission committee members should be based on the background and experience of faculty in student teaching, advising, mentoring, and coaching. Committee members should receive full-time equivalent credit with protected time. Further, promotion and tenure criteria should recognize their important contributions. All committee members must attend designated seminars/webinars addressing imposter syndrome, stereotype threat, resilience, mindfulness, wellness, social determinants of health, and health disparities. At institutions that allow, all committee members must have cultural humility, resilience, micro aggression, and implicit bias training before serving on the committee.21,25,26
Annual training must have measurable outcomes and demonstrate effectiveness, such as an increased number of admissions offered to BIPOC students, increased number of BIPOC admissions and matriculants, and an ongoing assessment of institutional climate change to one that is more inviting and inclusive. An assessment of institutional climate can be done through periodic surveys of faculty and students with tools such as the validated Diversity Engagement Survey from the AAMC and the Implicit Bias Association Test (IAT).22,42 Medical schools can also track student demographics and correlate minority admissions rates with changes in the institutional climate over time.42,43
CONCLUSION
The overall impact of the court’s ruling against race-conscious admissions extends beyond college admissions. It includes the admissions process at the professional level. Starting at the K-16 level, a low and static number of students from minority and marginalized populations somehow survive and progress academically to apply to and be considered competitive for admission to professional schools. In medicine, this starts at the K-12 level, where high school graduation rates for Black/African American and Hispanic students remain lower than White and Asian students and, subsequently, the ratio of high school graduates to college enrollees in selective colleges is disproportionately lower.44 Thus, we need to examine the medical school admission process at 2 levels: (1) pre-admission and (2) admissions.
A low number of BIPOC and marginalized students are admitted, matriculate, and join the health care workforce. In 2022, 56.5% of active physicians identified as White, 18.8% as Asian, 6.3% as Hispanic, Latine, or of Spanish origin, 5.2% as Black or African American, 0.35% as American Indian or Alaska Native, and 0.1% as Native Hawaiian or Pacific Islander.45 The current ruling will result in an even smaller pool of BIPOC students who will eventually pursue a career in health care, leading to a more homogenous and less diverse health care workforce.
Having a diverse health care workforce is critically important. It is well documented that patient outcomes are much improved when they are cared for by someone with shared experiences and background.46,47 A diverse and culturally prepared health care workforce is more able to provide quality care to an increasingly diverse population and is associated with multiple positive patient outcomes—increased access to care, greater patient involvement in and adherence to their care plan, higher quality of care, and more positive patient perceptions of care, all of which reduce health disparities and improve population health.46-49 In addition, a recent longitudinal cohort study of the primary care physician (PCP) workforce in US counties where there were Black PCPs, found that a higher level of Black representation within the physician workforce was directly associated with longer life expectancy and inversely associated with all-cause mortality rates and all-cause mortality rate disparities for Black individuals.50 The overall cost in morbidity and mortality to the public is unmeasurable.
As we move forward, we must become more innovative and engaging at all levels to ensure an adequate pool of students is available, encouraged, guided, and supported in pursuit of a career in health care. It boils down to the following: (1) development, support, and expansion of STEMM programs, (2) recruitment strategies at the K-16 level, (3) maintenance and enhancement of a holistic admissions process that includes an objective evaluation of an applicant’s experiences, attributes, and competences as well as a standardized and unbiased approach to assessing an applicant’s personal essay and lived experience, (4) intentional selection, support, and training of admissions committee members, (5) institutional safeguards, to ensure both applicant and institutional legal compliance during the application process, and (6) additional institutional funding and support to develop and consistently implement training. We can adapt and thrive.
Acknowledgments
We would like to acknowledge the much-appreciated input and editing of Ms Meredith Joheim, Science Editor/Writer, Science Communication Group (SciCom), University of Arkansas for Medical Sciences and Michael Anders, PhD, Associate Professor of Assessment and Evaluation and Director of Education in the Office of Educational Development, Division of Academic Affairs, University of Arkansas for Medical Sciences.
Footnotes
Conflicts of interest: author reports none.
- Received for publication December 9, 2023.
- Revision received September 30, 2024.
- Accepted for publication October 10, 2024.
- © 2025 Annals of Family Medicine, Inc.
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