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Commentaries

Holistic Review in Medical School Admissions and Selection: A Strategic, Mission-Driven Response to Shifting Societal Needs

Conrad, Sarah S. MS; Addams, Amy N.; Young, Geoffrey H. PhD

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doi: 10.1097/ACM.0000000000001403
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Abstract

Medical schools and residency programs have always sought excellence in the areas of education, research, and clinical care. However, these pursuits are not accomplished within a vacuum—rather, they are continually and necessarily influenced by social, cultural, political, legal, and economic forces. As a prime example, we are in the midst of a national movement shining a spotlight on persistent racial inequalities and injustices. From social justice advocacy initiatives to curricular reforms to increased emphasis on student wellness (e.g., offering safe and open forums focused on dialogue and healing), the medical community writ large and academic medicine specifically have clarified that meaningful social reform has a direct impact on the health and well-being of patients, communities, and learners. These realities, coupled with rapidly evolving biomedical research and a complex legal landscape, heighten our collective awareness and emphasize the continued need to consider medicine’s social contract when selecting, educating, and developing physicians and physician–scientists.

Selection—who gains access to a medical education and to a career as a physician, researcher, and/or faculty member—is as much art as science. This is particularly true now, given high application-to-seat ratios and limited resources. Quantitative assessments of applicants yield valuable, seemingly objective information, but they cannot convey context or tell the full story of an applicant and the paths they have taken. Human judgment, grounded in insight, expertise, experience, and evidence-based practice, remains a critical part of implementing selection processes that yield the desired outcomes. Holistic review, in promoting the use of strategically designed, evidence-driven, mission-based, diversity-aware processes, provides a conceptual and practical framework for marrying the art with the science without sacrificing the unique value that each brings.

Medical School Admission and Selection: A Brief History

It has long been understood that academic achievement is not the only requirement of a successful physician, and perhaps is not even the most important one. As early as the 1950s, many admissions committee members across the nation listed character and integrity as being more important for medical students and physicians than intellectual ability.1 A decade later, while attempting to identify ways to assess these essential if difficult-to-determine qualities, medical schools also began to more closely consider race and ethnicity when admitting candidates. This focus on race and ethnicity represented shifting cultural norms and a growing desire to address issues of social injustice and ensure equal access to education for all individuals. These early efforts, often but not entirely associated with affirmative action policies, were well intentioned but focused primarily on compositional diversity, with little emphasis given to institutional capacity to support that diversity. As a result, the promise of diversity failed to materialize, and it was therefore often viewed as being distinct from, and at times in conflict with, other institutional pursuits.2

Thinking steadily evolved, and research began illuminating the beneficial effects of diversity on the learning environment. As perspectives shifted, demographic characteristics, such as race, ethnicity, or geographic background, were viewed as potential assets to medical education and patient care. These benefits were recognized by Justice Powell in the Supreme Court’s 1978 Regents of the University of California v. Bakke decision.3 Powell approved a holistic evaluation of applicants, including the consideration of demographic characteristics in addition to academic metrics, explaining that a medical student “may bring to a professional school of medicine experiences, outlooks, and ideas that enrich the training of its student body and better equip its graduates to render with understanding their vital service to humanity.”3

Over the past several decades, knowledge of the benefits of diversity—and its critical but distinct companion, inclusion—has continued to expand. When strategically and thoughtfully implemented, diversity and inclusion have been shown to enhance the educational experience for all learners, lead to different research questions and greater amounts of research on marginalized populations and social determinants of health, and elevate the practice of medicine in hopes of ensuring culturally competent care for all patients.2

Holistic Review in Selection: A Potential Solution

Medical school admissions deans and committees are faced with the laudable though daunting task of carefully balancing individual characteristics, attributes, experiences, and academic readiness with the unique educational, research, and/or clinical needs of their institution. Furthermore, they must do this without losing sight of the needs of their community or nation. Dr. Darrell G. Kirch,4 president and CEO of the Association of American Medical Colleges (AAMC), argued that the health care needs of the nation’s increasingly diverse population require the transformation of medical school admissions, and encouraged medical schools to focus their efforts on a holistic admissions process.

Holistic review, though affirmed as defensible and effective in the Supreme Court’s recent Fisher v. University of Texas at Austin decision, has often been described in nebulous terms.5 Out of appreciation that having a shared vocabulary facilitates both implementation and evaluation, the AAMC defines holistic review as

a flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics and, when considered in combination, how the individual might contribute value as a medical student and physician.6

This definition acknowledges that academic metrics such as grades and standardized test scores should be considered as one of several important criteria and in the context of an applicant’s pathway to medical education. The AAMC has also developed a flexible framework shifting holistic review from a vague concept to an actionable process: Holistic review is mission based, evidence driven, integrated into all stages of the selection process, and applied equitably across all applicants, and it recognizes diversity broadly defined as central to achieving excellence. Importantly, and in support of Dr. Kirch’s proposal to transform admissions, this framework expands the lens through which applicants are viewed and encourages decision makers to consider the applicant not only as a future medical student or resident but also as a future physician.

Holistic review is now part of the standard lexicon in medical school admissions, and the vast majority of medical schools self-reported the use of one or more aspects of holistic review in their admissions process.7 Holistic review also emerged as a key theme in many of the 65 Amicus briefs filed in support of the University of Texas (UT) in the recent Fisher v. University of Texas at Austin decision by the Supreme Court. A variety of institutions of higher education and professional schools emphasized the link between holistic review and achievement of institutional goals. When that link is clearly established through holistic review, an institution’s or program’s mission and goals then become the foundation for admissions and selection criteria.8

Though the legal parameters for employment are different from those in admissions, the basic principles of holistic review are transferrable to other selection processes including residency selection and faculty hiring. In a 2015 Commentary by Prober and colleagues9 critiquing the overreliance on United States Medical Licensing Examination Step 1 scores in selecting residency applicants, the authors advocated for a “more rational” and holistic approach to residency selection that may include “community engagement, leadership roles, unique personal attributes, and diversity” in addition to competencies such as professionalism, patient care, and ability to function as part of an interdisciplinary team. And a recent program directors’ survey by the AAMC reaffirms the importance of applicant characteristics and competencies beyond medical knowledge, even as it highlights a lack of satisfaction with reliable tools to measure these competencies.10 The same thoughtful, strategic holistic review process can be applied to faculty selection and promotion.

Advancing Holistic Review

Holistic review and other diversity-related efforts are steadily evolving. A growing body of research illustrates the importance of aligning these efforts across the continuum of medical education in order to achieve goals.11 This alignment begins with institutional mission and the message that mission conveys to potential applicants and to the community. Consideration should then be given to enrollment strategies, curriculum and pedagogy, student support services, and faculty development. Similarly, as residency programs consider implementing more formal holistic review processes, attention should be paid to the pedagogies used and clinical learning environments in which residents learn. As with proposed efforts in undergraduate medical education, this intentional alignment will likely benefit all learners, as well as faculty and other participants in the clinical space.12

As important, evaluation of holistic review is vital to determine whether an institution’s policies, practices, and programs are enabling them to attract and matriculate the student body they want to educate and graduate.13 A comprehensive evaluation will also allow an institution to determine whether they are successfully supporting and leveraging that diversity to achieve their educational, research-related, and clinical goals.

This emphasis on evidence-based selection practices is at once a core principle of holistic review and sound legal and educational policy. Evaluation provides the data and evidence necessary to defend an institution’s or program’s specific need for diversity to key stakeholders, including the legal system.13 In those same amicus briefs set before the Supreme Court, another emergent theme was the importance of institutional research. Indeed, part of the success of UT can be attributed to their strong reliance on research and data when developing policies and practices. It is worth noting here that all of the evaluation need not be quantitative. Qualitative research and case studies yield valuable and different insights into learner, faculty, and patient experiences and provide rich ground for informing policy and practice.14

Finally, the selection process, and academic medicine in general, can only be optimized through collegial, transparent communication and collaboration among different stakeholder groups. Holistic review depends on a wide range of information about the applicant, and its success depends on applicants and schools or programs being able to make well-informed decisions about whether their mission and goals are aligned with policies and practices. The need for increased sharing as well as ongoing efforts to create more consistent, well-defined, and meaningful descriptions of performance in letters of recommendation and evaluation are documented in several of the articles in this issue. Additionally, there is a push for medical schools and residency programs to more clearly advertise the qualities, experiences, and academic metrics they seek in applicants and, where appropriate, factors associated with success in their schools or programs.15

In light of these issues, key stakeholders are working with one another to discuss ways to improve and enhance the selection process in both undergraduate and graduate medical education. Students, prehealth advisors, medical educators, admissions and student affairs officers, and program directors, to name just a few stakeholders, have different roles and different levels of investment in the academic medicine continuum. However, they share one common goal: to educate, develop, graduate, and train culturally competent physicians ready to address the rapidly evolving needs of the nation.

Conclusion

The demographic composition of the United States is markedly different than it was a decade ago, and the reality of persistent health and societal inequities along dimensions of race, religion, and gender identity, among others, has significantly challenged how academic medicine views itself and its role of caring for the sick. These challenges cannot be constructively addressed by the academic medicine community alone. Rather, it requires a systems perspective combining the forces of evidence-based medicine with those of policy makers, local and national communities, primary and secondary educators, and patients. New health care delivery and payment systems are being implemented, with more changes coming. Biomedical, public health, and population health research and practice are evolving at a rapid rate. Our health care system is transforming to address the needs of the nation—the student body and learning experience must transform in response. To seize attendant opportunities in academic medicine and aid in this transformation, mission-driven and evidence-based holistic review in admissions and selection must be intentionally integrated into the full continuum of physician education and development.

Acknowledgments: The authors would like to thank current and previous members of the Advancing Holistic Review Advisory Committee for their thought leadership, guidance, and tireless commitment to achieving diversity and equity. They would also like to thank S. Elizabeth (Liz) White for her substantial contributions to conceptualizing the holistic review framework and facilitating its implementation.

References

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