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Am I Disadvantaged? How Applicants Decide Whether to Use the Disadvantaged Status in the American Medical College Application Service

Lowrance, Adam M. MM, MA, PhD; Birnbaum, Matthew G. MA, PhD

Author Information
doi: 10.1097/ACM.0000000000002798
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Abstract

From the perspective of medical school applicants, the path to matriculation is high stakes, competitive, and ambiguous, and any missteps may lead to being eliminated from consideration at preferred programs. Given that more than 50,000 individuals apply for fewer than half as many first-year seats at U.S. MD-granting medical schools each year,1 the American Medical College Application Service (AMCAS) primary application represents the first and, for those not invited to interview, the only opportunity for admissions committees to evaluate prospective students.

Applicants have, as a part of the AMCAS primary application, the option to select the status “Disadvantaged” (i.e., “the Disadvantaged Status”) and describe the circumstances in an essay limited to 1,325 characters.2 The Disadvantaged Status may provide admissions professionals with additional context for understanding adversities that applicants have experienced along their paths to medicine; however, applicants receive minimal information on how the (potentially sensitive) details they share in their Disadvantaged Status essays might be used.

During the 2014, 2015, and 2016 admissions cycles (application years for participants in this study), applicants received neither an official definition of “disadvantaged” nor an explanation of how medical schools would use this status in their evaluations. The prompt provided in the AMCAS primary application in 2014–2016 read as follows: “Do you wish to be considered a disadvantaged applicant by any of your designated medical schools, which may consider such factors (social, economic, or educational)?”3 The application prompt continued, “If you answered Yes, please explain below why you believe you should be considered a disadvantaged applicant by your designated medical schools (1,325 characters).”3

Please note that for the remainder of this article, in recognition of concerns described both herein and by previous researchers, the word “disadvantaged” will be italicized. Many of our participants expressed their preference not to be labeled disadvantaged. We acknowledge the concerns of our participants and others for whom the term has negative connotations.

Background

As the U.S. population is becoming more diverse, medical schools are striving to reflect this heterogeneity in their enrollment. The Association of American Medical Colleges (AAMC)4,5 and others6 recognize that diversity in the physician workforce is critical to providing medical care to an increasingly diverse patient population. Amelioration of health care disparities begins with access to demographically concordant and culturally competent physicians.7,8 Physicians of a given racial or ethnic background are more likely to serve similar patient populations; patients are also more likely to attend appointments—and rate these visits more positively—when the physicians they see are demographically concordant.9 Differences in socioeconomic status (SES) can also affect the physician–patient relationship and, in turn, health outcomes. Researchers who have examined outcomes related to physician–patient concordance have noted that doctors sometimes stereotype patients from lower SES strata as less responsible and less intelligent; as a result, those patients do not always receive the same depth of explanation or treatment options.10–14 Overall, medical students from disadvantaged backgrounds are more likely, when they become physicians, to serve patients from similar circumstances than their non-disadvantaged peers.5,6,15,16

Traditional selection practices that overemphasize Medical College Admission Test (MCAT) scores and undergraduate grades have contributed to the long-standing underrepresentation of groups and individuals in medical education, research, and practice, particularly those who have faced hardships or barriers while preparing to be competitive medical school applicants.17–21 The AAMC recommends that medical schools replace the traditional selection process in which limited data are considered with a holistic approach that is “flexible” and “individualized” and “by which balanced consideration is given to experiences, attributes, and academic metrics.”17 Aligned with the tenets of holistic review, the Disadvantaged Status adds context through the elucidation of potential hardships and/or barriers that could have affected an applicant’s admissions preparation.

Few investigators have studied the Disadvantaged Status. Grbic and colleagues20,21 examined the efficacy of the recently implemented SES Disadvantaged Indicator through correlations with other AMCAS variables. The Disadvantaged Status had a moderate association (γ = −0.64) with the SES Disadvantaged Indicator; many applicants who used the Disadvantaged Status had limited educational and financial capital, placing them in the lowest 2 SES quintiles.21

Other research has focused on the term disadvantaged and how it has been used in medical education and other contexts. Price-Johnson described disadvantaged as connoting “a particular conception of diversity framed by the AAMC as more of a deficit than a robust factor when creating diversity.”22 Positioning applicants’ hardships as disadvantages marginalizes them, especially if they already associate the term with negative values. Espinoza-Shanahan23 observed that the term disadvantaged has been used in education to describe racial minorities whose academic outcomes are unsatisfactory. If individuals have negative views of the term, they may, in an effort to minimize the risk of negative attention, hide or conceal characteristics about themselves that others perceive as “less than”; they may even avoid using the option altogether.24–26

Method

Case study methodology guided this inquiry. Case study is one approach to inquiry that allows for exploration of a phenomenon in its natural setting.27 We collected the data for this study at a selective institution in the Northeast with small class sizes, referred to in this article as “The Medical School” (TMS); we have omitted the exact enrollment numbers and concealed the school name to protect the confidentiality of our participants. The University of Northern Colorado, our home institution, granted Institutional Review Board (IRB) approval. Because data involved sensitive topics, we worked closely with TMS administrators and IRB officials to recruit participants. A member of the TMS admissions office, serving as gatekeeper, was responsible for announcing the study to all first-, second-, and third-year medical students at TMS via the existing class email listservs. We imposed no limitations on study participation. The announcement included a general message in the gatekeeper’s own language, an attached consent form, and a list of interview questions. Students interested in participating could either contact us directly or communicate through the TMS gatekeeper. We scheduled the interviews and arranged AMCAS file access when the student participants provided their informed consent. Interviews occurred in the summer and early fall of 2016.

Before data collection, prospective participants (1) were informed of the research topic, (2) could opt into the study and were reminded that they could opt out at any time, and (3) were briefed on all conditions of informed consent. All interested medical students were accepted into the study.

Data collection and analysis

We collected the data used in this study from AMCAS files and one-on-one interviews. AMCAS files helped fill in background information and allowed for coding of personal statements, secondary essays, and, when applicable, Disadvantaged Status essays. Interviews were guided by 7 open-ended questions and conducted either in person or via videoconference, depending on participants’ availability. Interviews ranged in duration from 1 to 2 hours depending on how much participants wanted to share. Interviews focused on understanding participants’ backgrounds and their experiences with the Disadvantaged Status option on the AMCAS primary application. For example, one interview question asked, “Thinking back to your application, how did you want to be understood by admissions committees?” and included 2 follow-up probes: “What about yourself were you most eager to share?” and “What about yourself were you least eager to share?” Another question queried, “Had you ever considered yourself disadvantaged prior to the medical school application?” with accompanying probes for whether the participant answered “yes”—“Tell me about a moment when you felt disadvantaged”—or “no”—“Who do you envision when you think of a disadvantaged person?”

We (A.M.L. and M.G.B.) identify as white, heterosexual, cisgender, Jewish males, although such details were beyond the scope of the informed consent; the sharing of backgrounds was an important component of rapport building during the early stages of interviews with many of the participants. While both of us designed the study and worked on data analysis and interpretation, only one of us (A.M.L.)—who had received interview training—conducted the interviews.

First, the interviews were transcribed. Then, we analyzed the transcripts alongside participants’ AMCAS files immediately (rather than waiting until all interviews were completed) using a constant comparative approach through which we developed an initial set of codes that emerged from the participants’ responses. Codes were scrutinized for verisimilitude, relevance, and interconnectedness. Through the iterative process of moving between interviewing, transcribing, and word-by-word analysis, we were able to scrutinize interview questions and technique and then share any potential patterns with subsequent participants to gain their perspectives and account for potential blind spots in the inquiry.28

Social comparison and impression management

After we completed the interviews, we condensed the codes and considered them within the context of social comparison theory (SCT) and impression management (IM) to understand the emerged themes. SCT and IM are social theories that we found not only helpful for exploring the participants’ experiences but also quite relevant to making sense of them.

SCT suggests that in social situations, when objective data are not available, individuals rely on their known social contexts to make sense of their realities.29,30 For example, asking someone how much money they made last year might be considered rude, but the question can be answered objectively. Asking someone if they are poor is quite different—whose definition of poor is being invoked? Without objective criteria, individuals are likely to compare themselves with others with whom they are familiar. SCT is helpful in examining how applicants interpret disadvantage and how they determine whether they see themselves as such.

Goffman’s IM theories26 are useful in examining how applicants decide whether to apply as disadvantaged, especially within the asynchronous online application setting. According to IM, social interactions are embedded with ongoing efforts to shape the information individuals share with each other to control what others think about them. In face-to-face social interactions, individuals use the feedback they receive from others to assess the impression they are making; however, in asynchronous settings, such as the AMCAS primary application, feedback is not immediate, and individuals act with greater care to consider how to impart their desired impressions on their audiences.31

Results

Participants

The recruitment process yielded a mixture of 15 participants from the first-, second-, and third-year cohorts. Eight of these participants had applied as disadvantaged during their admission year, and 7 had not (see Table 1). Four participants identified with multiple races and ethnicities; 2 participants identified as queer, and 6 were from single-parent households (see Table 1 for details). No black medical students participated; this is expounded upon in Limitations (below). Participants chose their own pseudonyms and are referred to accordingly.

Table 1
Table 1:
Summary Profiles of Participants in a Study of Medical School Applicants’ Decisions to Invoke the Disadvantaged Status of the AMCAS Primary Applicationa

Coding

When we first began coding, we identified more than 60 codes within the transcript and AMCAS application data. We condensed these into 9 themes, within which SCT and IM were among the most prevalent. SCT and IM applied to, respectively, 169 and 138 data excerpts.

Understanding disadvantage and whether to apply as such

The task of deciding whether to apply as disadvantaged involved many considerations, broken down into a 3-step decision process. In the first step, participants had to decide what was meant by the term disadvantaged—that is, what meanings to ascribe to the concept in the context of the AMCAS application. Participants then needed to determine whether those criteria applied to them and, if so, to what extent. Finally, participants needed to determine how sharing such information would affect their applications. The results and ensuing discussion (below) are organized along this 3-step decision process.

Step I: Deciding what disadvantage means.

Participants were unclear on how to define disadvantage and how it would be used in the admissions process. One participant, who chose to go by the pseudonym The Hummingbird, reflected on what went through his mind when, as an applicant, he saw the Disadvantaged Status option. The Hummingbird lived much of his childhood in a crowded trailer, along with his mother and siblings; he slept on the couch, relied on government support, and was exposed to drugs and violence. He recalled, “I remember thinking, ‘I don’t know what the hell disadvantage means.’” Within the context of his own life, he met all of his preconceptions of what the term signified, but he was not sure what it meant within the context of the AMCAS application. All of the participants described similar feelings—a general frustration with trying to decide what definition of disadvantage the application was referencing. Jane shared, “I was unsure if I should be writing it.” Richard “remembered feeling uneasy. . . .” Ali confessed, “I honestly didn’t know what they meant by it.” Chris remembered “not really knowing what they were getting at, seemed like nobody knew what this was.” Sarah recalled asking 3 trusted resources, and when none were confident in their understanding of the term, she searched online. Sarah found only a few articles—none from the AAMC. Meghan, who decided not to identify as disadvantaged in an effort to avoid revisiting sensitive family issues, wondered:

What flavor of disadvantage are they asking about? Are they asking about my flavor, or are they going to laugh at my flavor? There are many ways you can be disadvantaged.

She went on:

It’s not that it doesn’t get at something important, but it’s just that it is one of those stupid vague prompts that they make up. . . . You are providing me no structure; it is incredibly ambiguous yet I have no power in this relationship.

Meghan thought the Disadvantaged Status prompt was “not a thoughtful way to ask the question.” Roger, who also did not apply as disadvantaged, remembered thinking the prompt led to more questions than answers. Charles, Richard, and The Hummingbird also believed that the AMCAS prompt for the Disadvantaged Status, given its focus on “social, educational, and economic” disadvantage, influenced the meanings they ascribed. Roger, Charles, Sarah, Richard, Matthew, and Kenny each discussed how the placement of the Disadvantaged Status prompt near financial and educational questions in the application influenced their framings.

Step II: Deciding whether they are disadvantaged.

Once arriving at their understandings of disadvantage, participants had to determine whether they qualified. Determining the degree to which they were disadvantaged was, for most participants, a challenging process that included comparing themselves with childhood and current peers. For example, Jane struggled to consider herself disadvantaged and did so only after being encouraged by peers. She recalled, as an applicant, assuming the prompt was reserved for individuals whose circumstances were more severe than her own. Despite growing up in a neighborhood where shootings and drug use were common and with peers whose only consistent source of nutrition was a free lunch at school, Jane had difficulty seeing herself as disadvantaged. By comparison with her social groups, Jane was never harmed or without food.

Charles shared that his childhood circumstances felt normal to him at the time. As a young child in rural China, he attended schools with overcrowded classrooms. His family immigrated to the United States and lived in a farming community with a large population of migrant workers and a poor school system. Charles explained: “When I was growing up. . . . I had no idea anything was amiss, but because I didn’t realize it, that doesn’t mean I wasn’t disadvantaged.” While Charles was aware of the conditions in which he found himself, his disadvantages were normalized. He reasoned:

Maybe someone who went to a high school where everyone had a Maserati, but they didn’t . . . might feel as someone would from a different sort of high school who didn’t have a car at all.

Charles’s analogy has illustrated how social comparison complicates what it means to identify as disadvantaged. Similarly, Chris explained that “somebody from [where I am from] will answer it differently than somebody who comes from a very affluent neighborhood.” Alex, a participant who did not apply as disadvantaged, described how his many childhood travels bolstered his understanding of the term and cautioned that applicants not “exposed to different cultures and living styles are at a higher likelihood to think that disadvantage is not applicable to them.” That is, travel and exposure to others may help students recognize their own hardships as potential disadvantages.

Ariadne and Sarah exemplified the influence of diverse socioeconomic exposure on applicants’ ability to see themselves as disadvantaged. They both came from low-income, single-parent, immigrant homes, yet they each attended private high schools with peers from predominantly high-SES backgrounds. Ariadne shared that while “friends spent breaks volunteering in Nicaragua or researching surgical outcomes,” she was “delivering a statement to police for a child abuse inquiry, or sopping up the contents of our burst water heater.” Similarly, Sarah explained that she could not afford to attend the orientation offered by her high school at the start of each year and that in the summers when peers would go on vacations, she “stayed at home babysitting.” Ariadne and Sarah were reminded throughout their formative years of their peers’ advantages; as a result, they were more prepared to see themselves as disadvantaged than some of the other participants.

Participants from socioeconomically depressed circumstances decided whether they could see themselves as disadvantaged based largely on social comparisons with their readily available peer groups—individuals encumbered by similar or even greater challenges. Such social comparisons confounded their ability to see themselves as disadvantaged when they were applicants.

Step III: Deciding whether to apply as disadvantaged.

Simply fitting within their own understandings of disadvantage did not mean that participants would apply accordingly. In the third step, participants considered how identifying as disadvantaged would affect their application. Even participants who shared experiences with extreme hardships wondered whether disclosing this information would harm their chances of admission. This uncertainty led to additional anxiety, self-doubt, and, in some instances, the decision not to use the Disadvantaged Status.

Sarah, Richard, Roger, Meghan, Chris, and Jane either did not apply as disadvantaged in large part because of fear of how their assertions would be judged or did so only after being convinced by trusted others. While Kelsey did not apply as disadvantaged, she empathized with applicants who struggle with the question: “I can totally see the hesitation because then that becomes how they sum you up.” Meghan, Jane, and Chris worried about whether their applying as disadvantaged would be viewed as appropriate or as embellishment.

Sarah, Matthew, Chris, Roger, Richard, Meghan, and Alex considered the impressions they would give if they identified as disadvantaged but did not meet the admissions committees’ expectations. Citing considerations similar to Meghan’s reference to the many “flavors” of disadvantage, Matthew hoped admission committees were aware that there are “many ways an applicant can be disadvantaged.” Chris thought there was a “secret code,” certain elements that committees looked for, and worried that “if you said the wrong thing,” the admissions process could be cut short.

Participants had to contend not only with their own thoughts on what it means to be disadvantaged but also with what they imagined admissions members to believe about the term, not to mention the views of family, friends, and peers. Many participants indicated discomfort with the idea of being described as disadvantaged. The last line of The Hummingbird’s Disadvantaged Status essay read, “I have never called myself disadvantaged, but if there were advantages to be had, we certainly didn’t incur them.” Other participants described that term as “seemingly disenfranchising,” “denigrating,” “not really how I see myself,” and as if those who used it might be “trying to say, ‘oh poor me.’” Participants desired to distance themselves from what they perceived as stigmatizing language; this added to the already complex process of deciding whether to use the Disadvantaged Status.

Because of perceptions of disadvantaged as a disenfranchising term, some participants recalled worrying about how their use of the Disadvantaged Status would reflect on their families. In reflecting on her decision not to apply as disadvantaged, Ana shared:

We were fortunate in that my parents worked very hard in order to put us through school . . . our family was so supportive . . . they put our education above basically everything else.

Chris was conflicted between self-advocacy and a desire not to use a designation he believed would tarnish his mother’s accomplishments. Chris, along with his 2 siblings, was proud of his single-parent mother. He explained that “even now my mom struggles to make ends meet” but went on to describe her as “the most incredible woman I have ever met.” Chris acknowledged that he is “kind of a prideful person” and saw using the Disadvantaged Status as “a footnote” in his and his family’s accomplishments. Ten of the 15 participants felt that perceived stigma associated with the Disadvantaged Status would detract from the way they viewed their upbringings.

Despite concerns of stigma, participants also considered possible benefits of using the Disadvantaged Status. Charles reasoned:

What does it cost to write the essay, like an hour of your time? And what is the potential gain from someone reading it, getting more consideration due to the fact that you are disadvantaged? Why would you not write it?

The Hummingbird described applying as disadvantaged as “a strong card” and thought of it as an opportunity to provide a complete picture of what he has accomplished despite where he came from, despite his start in life.

Similarly, Kenny described applying as disadvantaged as “a no brainer,” and while he assumed that using the Disadvantaged Status would gain favor with admission committees, he kept his Disadvantaged Status essay brief in the hopes of giving an impression of a “noncomplainer.” “Only the facts,” he explained.

Ethical concerns also affected participants’ willingness to apply as disadvantaged. Matthew considered that “you don’t want to position yourself as disadvantaged if it means displacing someone else who might be more disadvantaged.” Kenny imagined the possibility of “people who came from way tougher circumstances” than himself. Richard recalled some of his childhood peers and felt that even though he was similarly financially disadvantaged, the increased opportunities he had upon moving to the United States provided him a broader perspective. Alex also described the importance of understanding one’s place in society and noted that such perspective tends to increase with greater exposure to diverse experiences.

Like Richard, Roger had concerns about the right to use the Disadvantaged Status. Roger grew up in a rural farming community in California where his godparents worked as the only 2 physicians. Roger felt well-off compared with the many children of migrant workers with whom he attended school. Even just buying things like school supplies was a challenge for many of his peers. Roger admitted that he “very easily could have said ‘yes’ and wrote an essay about growing up around migrant farm workers and my underfunded public school system,” but he felt privileged by comparison. Roger elaborated, “It is hard for me to see people who, like myself, come from fancy colleges and then write an essay about how they feel disadvantaged.” Roger wondered at what point advantages gained (for example, in his case, baccalaureate and master’s degrees) made up for childhood hardships. Roger was not alone in this sentiment; participants made it clear that the process of deciding whether to use the Disadvantaged Status was anything but straightforward.

Discussion

To decide whether to apply as disadvantaged, the medical school students who participated in this study employed a 3-step process. The participants did not simply read the Disadvantaged Status prompt and make an immediate decision; rather, they first sought to understand what disadvantaged meant; then, they considered whether they qualified; and finally, they weighed the pros and cons of using the Disadvantaged Status.

Dissatisfied with the available resources to make sense of the Disadvantaged Status option on the AMCAS primary application, the participants in our study recalled feeling confused and frustrated as applicants. Simply having experiences with hardship was insufficient for most participants to determine whether they were disadvantaged and, if so, to a degree sufficient to justify applying as such. Participants believed official resources on the Disadvantaged Status (i.e., information provided by the AAMC) to be insufficient for understanding the meaning and purpose of the option. Recall Sarah’s reference to flavors (Step I of Results); “there are many flavors of disadvantage,” she explained, and wondered whether her version would be congruent with the admission committees where she applied. Without adequate resources not only for understanding what was meant by disadvantaged but also for determining whether they fit within those parameters, participants relied on social comparisons. Applicants’ identities—that is, how they saw themselves—was affected by who they made comparisons with; this aligns with results from previous research.30

As evidenced in this study, applicants with similar hardships may very well arrive at different understandings of disadvantage, different conclusions of whether they are disadvantaged, and different perceived benefits and risks regarding whether they should apply as such. Charles’s example of 2 students from similar SES backgrounds illustrates these different understandings and conclusions well. According to Charles’s example, one student (Student A) lives in an area and attends school where peers are socioeconomically similar; however, that student owns a car, albeit in rough condition, but a car nonetheless, whereas most peers do not. The other student (Student B) attends school with peers who come from higher socioeconomic backgrounds and drive higher-end vehicles. Because Student A’s peers do not have cars, the very fact that A does have a car, even one in rough condition, leads A to feel advantaged by comparison. Conversely, Student B, who has the same background and same car as A, compares him/herself with peers with higher-end cars and feels disadvantaged by comparison.

Applicants may identify as disadvantaged even if they have not experienced hardships comparable to those of others who use the Disadvantaged Status—simply because they compared themselves with more privileged peers than these other applicants. Likewise, another possibility, as observed in this study, is that applicants who have experienced significant disadvantages may refrain from applying as disadvantaged because they have compared themselves with peers who have experienced even greater challenges. These 2 scenarios represent major implications for applicants who must rely on social comparisons to make important decisions regarding whether to apply as disadvantaged.

The distinction between applicants who, as children, are immersed in educational and social worlds so disparate from their own and for whom feeling different, even “less than,” is unavoidable (e.g., Sarah, Ariadne), and applicants whose hardships are normalized by peers with similar backgrounds (e.g., Jane and Chris), points to the complexity of requiring applicants to rely on social comparisons in making their decision to apply as disadvantaged. Charles’s car example, along with the real-life cases of Ariadne and Sarah, illustrates the fragility of relying on social comparison to understand identity, especially within the construct of something as abstract and subjective as disadvantage. Further, as Alex points out, the usefulness of social comparisons is affected by both breadth and depth of one’s experiences, and such exposure tends to be affected by socioeconomic resources. In this study, participants with limited resources could not as easily determine whether they should apply as disadvantaged compared with those from higher socioeconomic backgrounds who did not have as much difficulty in realizing a heterogeneous social comparison group. Collectively, the participants’ experiences emphasize the subjectivity of social comparison and, in turn, the trouble of needing to rely on such contextual data to self-determine in the admissions process.

In the third step—deciding whether to apply as disadvantaged—participants exhibited aspects of IM. Through IM, we can study the motivations and behaviors of social interactions. Individuals form opinions about each other based on the information available (e.g., clothing, language, mannerisms, beliefs, professed attitudes).26 In general, people seek to act in ways that they believe their audiences will find pleasing in order to advance personal and professional goals; in this way, social perceptions and pressures influence not only what people believe about themselves but also the attitudes, beliefs, and mannerisms they share with others. The process of managing impressions is complicated further in asynchronous situations, such as the AMCAS primary application, in which visual and aural data of dialogic exchange are unavailable.31 In the absence of sufficient information (visual and aural cues) to understand the beliefs, attitudes, and expectations of the decision makers, applicants may opt to conceal elements of their identities that they believe could be perceived as undesirable or even stigmatizing.

The option of applying as disadvantaged created a dilemma for participants: How would anonymous and imagined reviewers interpret their hardships as applicants? Was sharing such information valuable? What impression does disclosing a disadvantage give, and is that impression congruent, even advantageous, with admission committees’ expectations for being a desirable applicant? Participants were aware of the importance of their impressions and sought to manage the information they provided.

Participants perceived negative connotations associated with the term disadvantaged and with incorporating disadvantage into a “status” that, as one participant worried, might be used to “sum you up.” These perceptions added to the complexity of deciding whether to apply as disadvantaged. Given what can be gleaned from participants’ experiences, the option of applying as disadvantaged as currently operationalized on the AMCAS primary application will likely continue to be used inconsistently and with hesitation. Ambiguity and negative connotations associated with the label may continue to stifle responses from applicants who could benefit.

Our study represents the experiences of 15 medical students at a single institution in the Northeast. Additional interviews from medical students at other schools, and from other admissions cycles, will advance the data on applicants’ experiences with the Disadvantaged Status on the AMCAS primary application. Furthermore, while participants’ demographics—ages, races and ethnicities, sexual orientations and gender identities, countries of origin, and SES—all varied, black medical students were not represented in this study. At the time of this study, few black students were enrolled at TMS; however, we cannot rule out other possibilities to account for their absence from this study—in particular negative connotations associated with the term disadvantaged and the historical use of this (and other similar terms) to describe black groups. The absence of black students in this study may very well reinforce the sentiment of previous researchers and all participants in this study—that the term disadvantaged is neither uplifting nor respectful of experience, whether of individuals or groups. Our hope is that additional studies will expand the scope of perspectives and experiences.

Conclusions

We believe the use of the Disadvantaged Status on the AMCAS primary application can contribute to a multidimensional view of diversity; however, further refinement is prudent. Admissions officers must be mindful of how the Disadvantaged Status is being used, especially by applicants with few resources, to determine what is meant by the term disadvantaged and to decide whether they qualify/should apply as such. At present, the lack of explanation regarding the Disadvantaged Status is contributing to applicants’ feelings of uncertainty about whether the option is for them. Applying as disadvantaged requires disclosure of personal details that may have led to marginalization in previous contexts. We believe a broad definition in conjunction with a more detailed explanation of its purpose will reduce ambiguity without jeopardizing diversity and inclusion. Such a revision to the AMCAS primary application should decrease applicant anxiety and empower applicants who might otherwise be hesitant.

Because participants described being influenced by the proximity of the Disadvantaged Status option and questions regarding financial, social, and educational background, it may be worth exploring its relocation within the application. And because participants echoed what other researchers have posited—that the term disadvantaged describes an applicant’s hardships or personal struggles through what may be considered negative language—we recommend revising the name of the status. Instead of labeling challenges in life as disadvantages, however disadvantaging they may be, perhaps using other language may position applicants’ life challenges more positively. We recommend including a diverse group of stakeholders, such as current medical students and recent graduates, in a discussion regarding revising the Disadvantaged Status label. For example, a change in nomenclature from Disadvantaged Status to something like Significant Hardship Designation may help with stigma concerns and reduce confusion with the similarly named Socioeconomic Status Disadvantaged Indicator. Until applicants believe that using the Disadvantaged Status will not harm their chances of admission, many will likely avoid the option.

References

1. Association of American Medical Colleges. Table A-1: U.S. medical school applications and matriculants by school, state of legal residence, and sex, 2018–2019. https://www.aamc.org/download/321442/data/factstablea1.pdf. Accessed September 26, 2019.
2. Association of American Medical Colleges. American Medical College Application Service. 2019 AMCAS Applicant Guide. 2018.Washington, DC: Association of American Medical Colleges.
3. Association of American Medical Colleges. AMCAS Application Data for Admission Officers. 2014.Washington, DC: Association of American Medical Colleges.
4. Association of American Medical Colleges. Roadmap to Diversity: Integrating Holistic Review Practices Into Medical School Admission Processes. 2010.Washington, DC: Association of American Medical Colleges.
5. Association of American Medical Colleges. Roadmap to Excellence: Key Concepts for Evaluating the Impact of Medical School Holistic Admissions. 2013.Washington, DC: Association of American Medical Colleges.
6. Isaac J, Davis K, Fike R, et al. An idea whose time has come: The need for increased diversity in medical practice and education. West J Black Stud. 2014;38:35–41.
7. Bradford JB, Cahill S, Grasso C, Makadon HJ. How to Gather Data About Sexual Orientation and Gender Identity in Clinical Settings. 2012. Boston, MA:Fenway Institute; https://www.lgbthealtheducation.org/wp-content/uploads/policy_brief_how_to_gather.pdf. Accessed April 11, 2019.
8. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient–physician relationship. JAMA. 1999;282:583–589.
9. Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care. 1988;26:657–675.
10. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33:1176–1187.
11. Pendleton DA, Bochner S. The communication of medical information in general practice consultations as a function of patients’ social class. Soc Sci Med. 1980;14:669–673.
12. van Ryn M. Research on the provider contribution to race/ethnicity disparities in medical care. Med Care. 2002;40(suppl 1):I140–I151.
13. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813–828.
14. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio-economic status of the patient and doctor–patient communication: Does it make a difference? Patient Educ Couns. 2005;56:139–146.
15. Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple predictors on generalist physicians’ care of underserved populations. Am J Public Health. 2000;90:1225–1228.
16. Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. Am J Public Health. 1997;87:817–822.
17. Association of American Medical Colleges. Using MCAT Data in 2019 Medical Student Selection. 2018.Washington, DC: Association of American Medical Colleges.
18. Kreiter CD, Stansfield B, James PA, Solow C. A model for diversity in admissions: A review of issues and methods and an experimental approach. Teach Learn Med. 2009;15:116–122.
19. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003.Washington, DC: National Academies Press.
20. Grbic D, Jones DJ, Case ST. Effective Practices for Using the AAMC Socioeconomic Status Indicators in Medical School Admissions. 2013.Washington, DC: Association of American Medical Colleges.
21. Grbic D, Jones DJ, Case ST. The role of socioeconomic status in medical school admissions: Validation of a socioeconomic indicator for use in medical school admissions. Acad Med. 2015;90:953–960.
22. Price-Johnson TN. The Cinderella Syndrome: A Case Study of Medical School Admission Decisions [dissertation]. 2013.Tucson, AZ: University of Arizona.
23. Espinoza-Shanahan CC. Understanding Disadvantage Among Medical School Applicants [dissertation]. 2016.Tucson, AZ: University of Arizona.
24. Goffman E. Stigma: Notes on the Management of Spoiled Identity. 1963.Englewood Cliffs, NJ: Prentice Hall.
25. Hannem S, Brucker C. Stigma Revisited: Implications of the Mark. 2012.Ottawa, Ontario, Canada: University of Ottawa Press.
26. Goffman E. The Presentation of Self in Everyday Life. 1959.Garden City, NY: Doubleday.
27. Yin RK. Validity and generalization in future case study evaluations. Evaluation. 2013;19:321–332.
28. Miles MB, Huberman AM, Saldaña J. Qualitative Data Analysis: A Methods Sourcebook. 2013.3rd ed. Los Angeles, CA: Sage.
29. Festinger L. Informal social communication. Psychol Rev. 1950;57:271–282.
30. Festinger L. A theory of social comparison processes. Hum Relat. 1954;7:117–140.
31. Birnbaum M. The fronts students use: Facebook and the standardization of self-presentations. J Coll Stud Dev. 2013;54:155–171.
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