When I was in the second grade, I remember receiving my first report card at the end of the school day. My friends and I compared our grades as we walked home from school, and one of my friends remarked that I had gotten a Needs Improvement grade for handwriting. The truth was that at age 7, I had terrible handwriting. No matter how hard I tried, I could not get my cursive letters to swirl and curve like the ski slopes my teacher expected. My letters looked more like mountain tops with jagged peaks, sheer cliffs, and deep valleys. And they degenerated into unreadable splotches when I tried to string together my letters to create words and sentences. I shouldn’t have been surprised at my poor grade because my teacher would often complain about how difficult it was for her to read my handwriting.
I held back my tears until I got home. My mother tried to console me and then tutor me, all to no avail. She even showed me examples of famous cursive writing, such as in the Declaration of Independence and the Bill of Rights with their beautiful cursive signatures, to provide inspiration for me to improve my efforts. We tried different pencils and different inks. The worst was the fountain pen, which caused all of my letters to run together in a pool. Eventually, the teacher and my mother hit upon a plan of allowing me to substitute cursive writing with individual printed letters, which seemed to work. I wrote that way until I learned to type and later to use word processing on computers, which ultimately solved the problem.
Why discuss the history of my handwriting in the pages of this journal?
I believe my experiences with handwriting illustrate that each of us has areas where we differ from others. Sometimes it can be how we look or talk or write—to name just a few possible differences. Sometimes we are stigmatized because of our differences. One of the great challenges of diversity is to appreciate our differences rather than fear them or make fun of them, and to understand that each person’s identity is made up of many interlocking facets and cannot be defined by any one of those facets.
With this attitude of appreciating differences, we in health professions education programs should be flexible enough to accommodate a diverse population of students, staff, and faculty. We will seek this flexibility if we are clear about the goals of our programs and do not lose sight of what is most important. For example, handwriting is an important method of communicating ideas, but it is the ideas that are most important, and there are many ways to communicate them, now even more than when I was in grade school. In my case there were ways to overcome my handwriting problem that were relatively simple. When it comes to issues of diversity in our educational institutions, the problems are harder to solve. I wrote this editorial to show how important it is for us to try, and what we might do.
Diversity as an important scientific concept goes back to Darwin,1 who extolled its virtues.
Should not variations useful to nature’s living products often arise, and be preserved or selected?.…I can see no limit to this power, in slowly and beautifully adapting each form to the most complex relations of life.
In health professions education, diversity has been identified as contributing to learning from dissimilar others, improving cultural competence to serve a diverse patient population, and fostering preparedness to care for minority and underserved populations.2 , 3 The Group on Diversity and Inclusion of the Association of American Medical Colleges (AAMC) crafted a definition of diversity that includes
all aspects of human differences such as socioeconomic status, race, ethnicity, language, nationality, sex, gender identity, sexual orientation, religion, geography, disability, and age.4
Diversity in health professions training, in addition to improving learning and attitudes, also helps meet the goal of workforce needs of the population. Graduates in the health professions must, ideally, go to the places where they are needed and care for diverse populations, particularly rural and underserved urban communities. Underrepresented in medicine (UIM) minorities and students from rural backgrounds are more likely to provide primary care in underserved communities.5 Additionally, there are substantial changes occurring in the health care system, and a diverse population of students may be more able to adapt “to the most complex relations of life,” as Darwin put it, and successfully innovate in the future health system, whether as clinician scientists, primary care doctors, surgical or medical specialists, or health system administrators. By supporting diversity in health professions education, we will begin to define diverse strengths and to appreciate, develop, and evaluate them.
While much of the discussion concerning diversity at academic health centers has lately focused on selection of students—which has led to recommendations for a holistic review process—we need to go further than selection and to identify which attributes are most important in our future health professionals and what we can do to nurture those attributes. Through such a process we will be able to respond effectively to concerns about race-based admissions policies such as those raised in the current Students for Fair Admissions lawsuit against Harvard University.6 In that lawsuit, Harvard has described a rating system in which it provides scores for academic, athletic, extracurricular, and personal qualities.6 Asian American students allege that in this system, an Asian American student with a 25% chance of admission would have a 35% chance if white, 75% if Hispanic, and 95% if African American with the same qualifications.7 These differences in the weighting of qualifications were not related to measurable academic achievement but were due to judgments in other categories. Is this an example of racial bias, or is it an appropriate application of holistic admissions? The answer may depend on judgments about the importance of personal attributes and experience and how they are assessed.
The AAMC Holistic Review Project has attempted to provide guidance to medical schools about how to assess an applicant’s experiences, attributes, and academic metrics as part of a fair, holistic admissions process.8 Witzburg and Sondheimer9 describe the implementation of holistic review at Boston University School of Medicine, which maps desirable physician traits onto applicant data. Intellectual ability, commitment to service, cultural sensitivity, empathy, capacity for growth, emotional resilience, strength of character, interpersonal skills, curiosity, and engagement are traits that are mapped onto specific data elements that could help assess those traits. While the authors assert that the adoption of holistic review has increased the numbers of UIM students—from 11%–12% prior to holistic review to 20% afterwards—holistic selection of students may not be perceived as fair to all students, especially by those rejected who had high grades and standardized test scores. Additionally, students who are selected using a holistic model for medical school may face a different set of criteria for selection to residency, related to medical school assessments and standardized tests, that could put them at a disadvantage for highly competitive residency programs.
Teherani et al10 address the effects on UIM students of a competitive process for granting medical school clerkship honors and Alpha Omega Alpha (AOA) Honor Medical Society membership. They assert that standardized clerkship exam results represent the long-term consequences of structural inequities, and that institutional grading policies that place excessive weight on small differences in exam scores may be inappropriate. They describe an “amplification cascade” where small differences in assessed performance lead to larger differences in grades and selection for awards. Their solution is to move away from the current limitations on the number of honors grades to a criterion system where honors grades are not limited.
Wijesekera et al11 in this issue identify similar disparities of honor society induction. They found that African American medical students were less likely to be inducted into AOA but not into the Gold Humanism Honor Society and that women were more likely to be inducted into the Gold Humanism Honor Society but not into AOA. Their findings that African American students had lower clerkship grades raised concerns about bias in grading and the selection process for AOA. Hauer and Lucey,12 also in this issue, suggest that core clerkship grades be replaced by competency-based assessment for learning, reasoning that the core clerkship grades disadvantage those students who are not familiar with the criteria and culture of clerkship grading and that an assessment for learning competencies would be more specific and appropriate at the early stages of clinical education.
If we are to eliminate core clerkship grades and reconsider the selection criteria for AOA membership, other comparative data like scores on the United States Medical Licensing Examination Step 1 might take on increased importance for residency selection, which could also disadvantage UIM students who were selected for medical school using a holistic review.13 Is there a better way to develop a truly holistic picture of a medical school applicant that would be both fair and efficient and also align with public needs for a diverse workforce? I think there is.
First, I think that holistic admissions can be made more efficient and fair by understanding the history of previous selection processes. Since holistic admissions requires an assessment of personal attributes as well as test scores and grades, it is important that selection committee members have, as a group, a wide spectrum of attributes so that the attributes of all applicants, not just some of them, are represented. In addition, the effects of the holistic process need to be constantly reexamined so that if a situation arises like that identified in the current Harvard lawsuit, it can be analyzed and changes made if needed to meet diversity and academic goals.
One reason that merit-based selection replaced the previous selection system for colleges at the beginning of the 20th century was that it was more fair to those students who had previously been denied admission because of race, religion, or class by selection committees that were not diverse. Historical accounts of quotas and biases provide important context to explain mistrust of selection committees. In that regard, Thomas and Dockter14 in this issue recount the history of affirmative action and holistic review and how they have evolved over time. I maintain that a holistic review system can meet diversity goals only if it is staffed with diverse members with broad experience who understand the history of bias in selection, confront their own biases, and recognize those of past selection systems.
Second, I believe we can align holistic admissions systems with community and population needs, using incentives that encourage students to pursue careers in places where they are most needed, such as rural and underserved areas. Goodfellow et al,5 in a systematic review of predictors of primary care physician location in an underserved area, found that underrepresented minority physicians were more likely to locate in underserved areas and care for minority patients. Recipients of National Health Service Corps scholarships that provided incentives to practice in underserved communities in exchange for tuition and living expenses were more likely to practice in underserved communities upon the completion of obligations.5 Medical school programs and graduate medical education programs with rural or underrepresented community experiences and rotations also have a positive influence on physicians’ decisions to practice in underserved communities.5 Since one of the goals of the medical education system is to provide physicians for the country’s entire population, a holistic admissions system could (1) consider applicants with life experiences and personal attributes that suggest they might choose to practice in underserved areas, and (2) advocate incentives to support the education expenses of students who commit to practice in those areas.
Finally, I would like to reiterate the words of Nivet,15 published in this journal in 2015: “Institutions that wish to achieve excellence must integrate diversity and inclusion into their core workings.” I believe that for holistic admissions to work as it should, it has to be part of a larger institutional commitment to diversity, including the leadership of the institution, the development of curriculum, and the assessment system for students. Anything less will ultimately fail because it will lack the commitment and resources that flow to those key institutional factors, which are integral to fostering the core values of an organization.
Three articles in this issue describe the types of steps that help change an institution’s core values and behaviors in ways that can strengthen the holistic admissions process for students and residents. Krishnan et al16 describe an approach to revise teaching cases to address inequality in educational materials. The implications of their work are that implicit messages of our teaching materials should be scrutinized so that our curricular materials support the values of diversity and equity that we espouse. Jones et al17 discuss educating for indigenous health equity (i.e., health equity for a country’s indigenous people). If we wish to contribute to health equity by understanding and improving indigenous heath, we need the road map that consensus statements such as theirs can provide. Finally, Polk et al18 describe a partnership between an academic medical center and a community clinic for the care and education of Baltimore’s growing Latino population (many of whom are undocumented immigrants). Our actions as well as our words provide messages about what we value, and partnerships with clinics that serve minority populations send a strong message.
I do not believe we have to sacrifice excellence to get diversity. And we need to define excellence and diversity broadly and inclusively. If we do that, excellence and diversity can go hand in hand, holistic admissions can grow and flourish, and the health professions workforce can better serve all our country’s citizens.
David P. Sklar, MD
1. Darwin C. The Origin of Species. 1859.London, UK: John Murray.
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3. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008;300:1135–1145.
5. Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of primary care physician practice location in underserved urban or rural areas in the United States: A systematic literature review. Acad Med. 2016;91:1313–1321.
7. Students for Fair Admissions, Inc. v president and fellows of Harvard College. US Dist Court for the District of Massachusetts. June 15, 2018.
9. Witzburg RA, Sondheimer HM. Holistic review—Shaping the medical profession one applicant at a time. N Engl J Med. 2013;368:1565–1567.
10. Teherani A, Hauer KE, Fernandez A, King TE Jr, Lucey C. How small differences in assessed clinical performance amplify to large differences in grades and awards: A cascade with serious consequences for students underrepresented in medicine. Acad Med. 2018;93:1286–1292.
11. Wijesekera TP, Kim M, Moore EZ, Sorenson O, Ross DA. All other things being equal: Exploring racial and gender disparities in medical school honor society induction. Acad Med. 2019;94:562–569.
12. Hauer KE, Lucey CR. Core clerkship grading: The illusion of objectivity. Acad Med. 2019;94:469–472.
13. Moynahan KF. The current use of United States Medical Licensing Examination Step 1 Scores: Holistic admissions and student well-being are in the balance. Acad Med. 2018;93:963–965.
14. Thomas BR, Dockter N. Affirmative action and holistic review in medical school admissions: Where we have been and where we are going. Acad Med. 2019;94:473–476.
15. Nivet MA. A Diversity 3.0 update: Are we moving the needle enough? Acad Med. 2015;90:1591–1593.
16. Krishnan A, Rabinowitz M, Ziminsky A, Scott SM, Chretien KC. Addressing race, culture, and structural inequality in medical education: A guide for revising teaching cases. Acad Med. 2019;94:550–555.
17. Jones R, Crowshoe L, Reid P, et al. Educating for indigenous health equity: An international consensus statement. Acad Med. 2019;94:512–519.
18. Polk S, DeCamp LR, Vázquez MG, et al. Centro SOL: A community–academic partnership to care for undocumented immigrants in an emerging Latino area. Acad Med. 2019;94:538–543.