Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.
—Robert Frost, “The Road Less Traveled,” Mountain Interval, 1920.
In this issue of Academic Medicine, Talamantes and colleagues1 analyze the role that community colleges play in preparing aspiring applicants for medical school. They note that underrepresented minorities (URMs) and first-generation college students are much more likely to attend community college first and then transfer to a four-year college than are white students and those with college-educated parents. Despite medical schools’ professed interest in recruiting minority applicants and those who come from modest backgrounds, the authors found that community-college-first applicants were significantly less likely to gain admission to medical school than students who directly matriculated to more selective four-year institutions.1 Because the cost of college is becoming unaffordable for a growing number of low-income and middle class families, the disconnect between who medical schools say they want and who they actually admit is sobering. If the leaders of U.S. medical schools are serious about reducing social and economic barriers to entry, they must reconsider the criteria they use to judge a candidate’s qualifications for admission.
Separate and Unequal
The “American dream”—the idea that anyone in the United States who works hard enough can succeed, regardless of their social standing—has inspired Americans since colonial times. As a nation, we believe that all who go the extra mile should be given a chance to prove what they can do. Given the power of this idea, it is difficult to reconcile the community colleges’ promise of availability, affordability, and betterment with the reality of medical school admissions.
It has been recognized for years that URMs and financially disadvantaged students rely heavily on community colleges. In their 2013 report, Carnevale and Strohl2 noted that, between 1995 and 2009, black and Latino student enrollment in postsecondary institutions grew by 107% and 73%, respectively. Although this was a welcome trend, most of the enrollment growth of URMs occurred at less selective, “open-access” institutions (i.e., two-year community colleges and four-year schools that admit more than 80% of their applicants).2,3 White enrollees continued to dominate enrollment at more highly selective four-year schools where per-student spending is more than twice that of open-access colleges, and where students have access to robust prehealth advising, volunteer, and shadowing opportunities.2,4 At the end of the 14-year study interval, the difference was striking: 68% and 72% of new black and Latino freshman students, respectively, were enrolled at open-access schools, whereas 82% of new white freshmen students were enrolled at more selective four-year schools (see Figure 1).
Carnevale and Strohl’s2 conclusion was scathing: “The postsecondary system,” they wrote, “mimics the racial inequality it inherits … magnifies and projects that inequality into the labor market and society … in theory, the education system is colorblind … in fact, it is racially polarized and exacerbates the intergenerational reproduction of white racial privilege” [emphasis added].
Community College Graduates
What they and many others have shown me is that I am not a waste of life. That I have not been defeated and that I am worth investing in. And for that I will forever be grateful.
—Michael Anthony Moynihan, a 2013 graduate of North Seattle Community College, speaking of his teachers and the school that gave him a chance5
Given the societal imperative to boost URM enrollment, one might expect medical school admissions committees to be favorably inclined towards high-achieving applicants who begin their postsecondary career at a community college. In fact, the opposite appears to be true. Talamantes and colleagues determined that even after other important characteristics such as applicant age, gender, race, ethnicity, parental education level, grade point average (GPA), and Medical College Admission Test (MCAT) scores are taken into consideration, students who attended community college first (First-CC) and subsequently transferred to a four-year institution for their bachelor’s degree were significantly less likely to be accepted to medical school than students who enrolled directly in a four-year college. All else being equal, only 31% of First-CC applicants achieved a spot in medical school, compared with nearly half of applicants from four-year colleges and universities.1
How important can community colleges be in boosting medical school diversity? Consider this: A 2011 report from the National Center for Public Policy and Higher Education found that whereas only 28% of white students get their start at a community college, half of Latino students and nearly one-third of black students do (for comparison, the general population is 13.1% black and 16.9% Latino).6,7 Even more remarkable still, 44% of low-income students and 38% of students whose parents did not obtain a college degree start their postsecondary academic pursuits at a community college. In contrast, only 15% of high-income students and 20% of those whose parents are college graduates get their start there.7 If medical schools are serious about enhancing racial, ethnic, and socioeconomic diversity, these numbers should matter.
So why are community college students less likely to get into medical school? There’s no evidence that students who get their start at a community college are less intelligent than those who enroll in a four-year institution. In fact, research indicates that many community college students from disadvantaged economic backgrounds would be quite competitive for admission at more selective schools, if they chose to apply. Hoxby and Avery,8 for example, determined that more than 40% of high-achieving low-income students apply to community colleges and other “nonselective” schools with entry criteria far below their “safety level” (i.e., the school’s median test scores are significantly below the applicant’s own). In contrast, high-achieving students from wealthy households generally spurn “safety schools” to pursue “reach” colleges with big sticker prices. Interestingly, when high-achieving low-income students enroll at selective schools, they generally do as well as their wealthier peers.
Studies like this one indicate that community colleges attract many high-achieving applicants who, for any of several reasons—limited finances, inadequate advising, insufficient financial aid, or a need to stay close to home—choose not to enroll in a four-year college right away. Unfortunately, Talamantes and colleagues’ findings suggest that students who opt to attend community college first place themselves at a disadvantage when the time comes to apply to medical school.
We Must Practice What We Preach
Liaison Committee on Medical Education (LCME) accreditation standards IS-16 and MS-8 direct medical schools to pursue institutional diversity. Standard IS-16 reads, in part, that “an institution … must have policies and practices to achieve appropriate diversity among its students … and must engage in ongoing, systematic, and focused efforts to attract and retain students … from demographically diverse backgrounds.” MS-8 states that “a medical education program must develop programs or partnerships aimed at broadening diversity among qualified applicants for medical school admission.”9
If community colleges are as rich a source of qualified URM applicants as they appear to be, why aren’t more community college graduates admitted to medical schools? One reason is that not enough apply. According to Talamantes and colleagues,1 only 7.4% of the 40,491 applicants who used the American Medical College Application Service (and for whom complete data were available) were First-CC students. These students’ reluctance to consider a career in medicine may be due to real or perceived obstacles, such as lack of confidence, inadequate knowledge of premed requirements, prehealth advisors who steer them to other fields, or the belief that medical school is financially out of reach.
Low application rates are part of the problem; low acceptance rates are the other. Considering the resources available to them, no one should be surprised that Talamantes and colleagues found that four-year college graduates had somewhat higher mean GPAs and MCAT scores than First-CC graduates, but the difference was modest (mean GPA and MCAT scores among those not attending community college were 3.55 and 29.0, respectively, versus 3.49 and 26.2 for First-CC grads). However, Talamantes and colleagues1 found that even after GPA and MCAT scores were taken into consideration, First-CC students were less likely to be admitted.
Other factors may explain the difference. For example, First-CC applicants are less likely to have the research and extra curricular experiences that many admissions committees favor. Not only are four-year institutions more likely to offer these experiences, their students have more opportunities to participate. It is hard for a student to find time to participate in an “extracurricular activity” when he or she comes from a lower-income background and is working his or her way through school.
Most worrisome is the possibility that bias is skewing admissions committee decisions. Rather than recognizing the “distance traveled” by low-income and URM applicants who get their start at a community college, some committee members may be consciously or subconsciously inclined to discount their academic achievements because they were compiled at a less “academically rigorous” institution than a research-intensive university. This is precisely the sort of thinking that Carnevale and Strohl2 so roundly condemned.
The F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences (USU) is the only LCME-accredited school of medicine owned and operated by the U.S. government. Established at the end of the Vietnam War to produce physician–leaders for the military health system, USU accepts applicants from across the country and trains them for medical practice around the world. Although a third of our entering students have prior military experience, two-thirds do not. Because all of our students attend USU tuition-free, cost is not a barrier to entry.
Given USU’s unique mission, successful applicants must not only be able to master the standard medical school curriculum; they must also possess the leadership qualities, integrity, and resilience necessary to become outstanding military officers. Group dynamics matter as well. In our view, an ideal class should reflect the diversity that defines us as a nation.
To encourage applicants from diverse backgrounds, we credit community college course work to meet our pre requisites. To reassure some of our committee members who might other wise question the ability of First-CC students to master rigorous classes in medical school, we encourage First-CC students to take additional upper-level sciences courses after they transfer to a four-year college or university. Because a number of our applicants come from the U.S. military’s enlisted forces, we recognize premedical course work completed at different institutions over several years—including courses taken at community colleges. To attract even more high-achieving applicants from this pool of talented individuals, we are working with the U.S. Air Force, Navy, and Army to launch an “Enlisted to Medical Degree” preparatory program. It will identify promising enlisted personnel—including those who had their start at a community college—to complete their prerequisites for medical school while remaining on active duty. Finally, like many other medical schools, we partner with community colleges in our area to encourage their students to pursue careers in the health professions. In time, we hope to take this effort nationwide.
One of the unique strengths of USU is that we can offer low-income and first-to-college students a debt-free path to a medical degree. The Armed Forces’ Health Professions Scholarship Programs (military scholarships for medical school) and the National Health Service Corps scholarship program (the Public Health Service’s scholarship program) also offer full scholarships in exchange for a period of national service. There are many more national, state, local, and school-specific scholarships that can help defray the cost of a medical education. But to qualify for one of these scholarships, a student must first gain admission to medical school.
The Bottom Line
Talamantes and colleagues1 challenge us to confront the disconnect between our desire to enroll high-achieving students from diverse backgrounds and the tendency of admissions committees to discount the achievements of First-CC applicants. If we are serious about lowering the social, racial, and economic barriers to medical school, we must start viewing two years of premedical education at a community college as an asset rather than a liability. Once we do that, the “road less traveled” will become a surer path to medical school and, hopefully, to a healthier population.