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Invited Commentaries

Affirmative Action and Holistic Review in Medical School Admissions: Where We Have Been and Where We Are Going

Thomas, Billy R. MD, MPH; Dockter, Nancy MPH

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doi: 10.1097/ACM.0000000000002482
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On August 1, 2017, the New York Times reported that President Trump’s administration was preparing to redirect resources from the Department of Justice’s Civil Rights Division to investigate and possibly sue colleges and universities over alleged intentional race-based discrimination in their admissions policies and practices.1 Although this claim did not mention specific races (or ethnicities), medical schools across the country raised concerns about continuing their holistic admissions processes because of a fear of potential retribution.

Race-conscious admissions policies are currently legal, as set forth by the Supreme Court.2 To help standardize holistic admissions processes, which can consider race among other attributes, the Association of American Medical Colleges (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 that may enhance their ability to provide care to minority and underserved communities.3 This evidence-based approach helps the AAMC and medical schools fulfill their mission to grow a diverse and culturally prepared health care workforce and helps to ensure that every applicant receives individualized consideration.3 The purpose of this Invited Commentary is to discuss support for the use of holistic review in medical school admissions to foster a diverse student body and to suggest a way forward given current challenges to such policies.

Benefits of a Diverse Health Care Workforce

Cooper and colleagues4,5 described a self-aware clinician as one who understands her own background, attitudes, and values and how they shape her behavior and interactions with others in the context of health care. This self-awareness may be at the core of patient–provider relationships and directly reflected in patients’ trust, openness, and adherence to recommendations and follow-up, all of which can lead to improved patient care and outcomes. Students from minority and underserved communities bring with them experiences and perspectives that can affect their daily interactions as trainees, touching others in their sphere as they participate in academic houses, small-group team-based learning, student-led organizations and committees, community service, and classroom learning. This influence continues during their subsequent training and practice.

A 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.2,5,6

Holistic Admissions in Higher Education

Institutions that foster diversity tend to be inviting and nurturing places where all students and faculty can thrive. Student body diversity is associated with increases in students’ academic performance, retention, community engagement, cooperation, and openness to different ideas and perspectives.7 Success of the holistic admissions process is not measured by reaching a preset quota of diverse students but, rather, by achieving a level of diversity that is associated with a discernible reduction in reported incidents of discrimination, bias, stereotyping, and exclusion and with an increased sense of belonging on the part of minority students.8

Alternative strategies to holistic review, such as the consideration of socioeconomic factors and high school percentage plans, which have been implemented in states with affirmative action bans, have resulted in an immediate and sharp decline in the number of students from underrepresented groups admitted to the states’ most selective public institutions. Subsequent efforts to restore these groups’ enrollment rates to preban levels have not been effective,6,9–11 and in some cases enrollment rates remained below preban levels for more than a decade (see Table 1).12,13

Table 1
Table 1:
Total Enrollment and Undergraduate Enrollment, by Race/Ethnicity, at U.S. Colleges and Universities in States With Affirmative Action Bans, Pre (1994) and Post (2007) Bana

In higher education’s ongoing pursuit of fair and socially relevant admissions policies, socioeconomic status (SES) has been suggested as a proxy for race. Although critical to the admissions process, SES is no substitute for race or ethnicity as a uniquely meaningful factor to consider. At best, it should be viewed as complementing race.14 An admissions process that considers SES in place of race does not yield the same numbers of African American and Hispanic applicants admitted as a process that considers race. At select colleges, low-SES applicant pools have a much greater proportion of white applicants than underrepresented minority applicants; when only SES is considered, the number of underrepresented minority applicants admitted to those schools decreases significantly. To maintain current levels of minority enrollment, the number of colleges with SES-based admissions processes that exclude race would have to increase fivefold, according to some estimates.6,15–17

An applicant’s chances of admission to a college or medical school are greatly influenced by her social capital—the networks in her life that enable her to function effectively. Minority and economically disadvantaged students typically have less social capital. The Supreme Court decision, Brown v. Board of Education, declared that laws mandating separate schools for black and white students were unconstitutional. Although that ruling was issued 64 years ago, our school systems still lack racial equity, and even in those schools with racial balance, segregation persists at multiple levels. Minority students are more likely to attend schools lacking the resources needed to fully prepare them for college or medical school, such as Advanced Placement courses, especially in science, technology, engineering, and math (STEM) subjects; career counseling; tutoring; mentoring; shadowing; and exposure to the health professions. The cumulative effect is that many minority students will not be as competitive as majority students in nonholistic review admissions processes.18–21

Affirmative action came out of the Civil Rights movement of the 1960s and the passage of the Civil Rights Act of 1964 and the Voting Rights Act of 1965. The centerpiece of the Civil Rights Act was Title VI, which states that no person in the United States shall, on the grounds of race, color, religion, sex, or national origin, be subjected to discrimination by any program receiving federal funding. Beginning with the 1978 Regents of the University of California v. Bakke case that came before the Supreme Court, challenges to race-conscious admissions have focused on the legality of admissions policies under Title VI of the Civil Rights Act.

In 1965, President Johnson introduced affirmative action as a means to move beyond nondiscrimination, to a more proactive, affirmative method for increasing opportunities for black Americans in the business and labor markets. In the years that followed, colleges and professional schools realized the importance of educating a diverse student body and initiated programs to recruit minority students and to take race into account in admissions; these processes were race-conscious forerunners to today’s holistic admissions processes.22 Although affirmative action and holistic admissions are intricately and longitudinally linked, holistic admissions does not target specific racial, ethnic, or gender groups, and there are no quotas or set-asides. Holistic admissions takes into account multiple factors about each applicant, including lack of social capital, race, ethnicity, gender, status as a first-generation college student, SES (which includes K–12 education, higher education, and family wealth and income), geographical location, past experiences with minority and underserved populations, and immigration status.

The Supreme Court and Holistic Admissions

The use of race as a factor in admissions has been upheld in three Supreme Court decisions: Regents of the University of California v. Bakke (1978), Grutter v. Bollinger (2003), and Fisher v. University of Texas (2013). However, the position of President Trump’s administration makes its future uncertain. In addition, changes to the Supreme Court and current and anticipated vacancies on district and appellate courts could affect future decisions.23,24

The Way Forward

As demographics shift toward a projected “browning” of America and a majority minority population by 2050, we have reason to be optimistic that the inclusion of all individuals regardless of race, ethnicity, gender, religion, sexual orientation, gender identity, and disability status will become the cultural norm.25–28 Meanwhile, we must be sensitive to the fact that some segments of the population still routinely experience discrimination, bias, marginalization, exclusion, and limited economic mobility.29 We must also be aware that there are those who oppose diversity and inclusion and want to abolish affirmative action policies.

Higher education remains the gateway to upward mobility.6 Attainment of a bachelor’s degree is seen as the tipping point at which the intergenerational effects of race and poverty are partially overcome.6 Denial of fair access to higher education and the possibility of upward mobility to qualified applicants is as harmful as redlining in housing markets, racial bias in hiring, and racially discriminatory lending practices. Holistic admissions processes are critically important not only to the students who are seeking a chance to prove themselves but also to society as a whole.

The Supreme Court likely will rule again on race-conscious holistic admissions policies. Until then, we must challenge those who oppose such practices and the existing legal standards. We recommend that medical schools pursue the following activities to identify, nurture, and retain underrepresented and minority students.

Maintain or increase support for STEM-based academic enrichment programs at all levels

Over several decades, these 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 of which increase their social capital and help them overcome academic deficits that begin before kindergarten in many cases.9 These programs also help medical schools identify qualified applicants who, after matriculation, can be nurtured, supported, and retained as they pursue their training.

Foster the success of minorities by staying informed about institutional climate

Periodic surveys of faculty and students using tools such as the validated Diversity Engagement Survey from the AAMC can help schools understand their institutional climate.30 At the University of Arkansas for Medical Sciences, we recently conducted this survey and found that minority faculty and students were more likely to have feelings of isolation, mistrust, and loneliness. Data from this survey at institutions that employ race-conscious admissions policies can be instrumental in evaluating the effectiveness of those policies and the merits of their continued use. Notably, the Fisher v. University of Texas decision identified minority students’ perceptions of loneliness and isolation as key baseline factors for demonstrating whether the educational benefits of diversity have been achieved. Medical schools can also simply track student demographics and correlate minority admissions rates with changes in the institutional climate over time.30,31

Support a holistic admissions process that considers race and SES

Intergenerational inequality is powered by both SES and race. Although these two attributes are different, they do overlap, and both affect educational and economic success.6 To overcome inequality and achieve racial and economic diversity, some combination of SES- and race-conscious admissions criteria likely will be required.6 A holistic admissions process that includes both attributes can increase the number of African American, Hispanic, and lower-income students who gain access not only to top-tier colleges but also to a college education in general.

This approach will help minority and disadvantaged students overcome the intergenerational barriers created by race, ethnicity, and poverty,6,9 and it will help us grow a diverse and culturally competent health care workforce, which is essential to improving individual and population health and narrowing racial and ethnic health disparities.

Acknowledgments: The authors thank the University of Arkansas for Medical Sciences Translational Research Institute staff (grant 1U54TR001629-01A1 through the National Center for Advancing Translational Sciences, National Institutes of Health) for their support. The authors also thank Dr. Jean Chi-jen Chen, University of Arkansas for Medical Sciences, for her statistical analysis.


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