The Measure of a Medical School: Who Gets In and What They Choose to Do

 From the July 7, 2023 issue of the Transformational Times

The Measure of a Medical School: Who Gets In and What They Choose to Do

Adina Kalet, MD, MPH

In this week’s Transformational Times, we share highlights from the Second Annual Equity in Education Summit co-sponsored by the Kern Institute and the Office of Student Diversity and Inclusion in April 2023. Dr. Kalet reminds us why we need to conference regularly to negotiate our social mission ...

 

A medical school addresses its social mission through its admission policies/practices, curriculum, and generational investments. In the US, medical education is a scare resource. Overall acceptance rates lately are around 43%, with some individual schools accepting fewer than 5% of applicants. Since almost all medical students who matriculate will eventually graduate, we have the awesome privilege and responsibility of composing the physician workforce through our selection of medical students from among a rich pool of academically qualified candidates. 

How should we decide who gets in? 

Honoring our social mission as a medical school is neither easy nor simple. We are expected, through our social contract, to align our educational, research, and service activities so that they address the health concerns of the local, regional, or national community we serve. But societal needs are vast, complex, and ever evolving. So how, year after year, do we consistently compose a class and educate future physicians who will attend to the health of the community and leave it better off? 

It is too simplistic to rely only on academic metrics to determine a candidate’s merit. That approach is not fair. The Medical College Admissions Test (MCAT) scores and undergraduate Grade Point Averages (GPA) are valuable when identifying the pool of students able to handle the academic rigor of the earliest stage of medical education, but numeric criteria predict neither who will make excellent physicians nor who will serve medicine’s social mission by practicing in diverse geographic locations or choosing specialty training based on the needs of the community. We need to be thoughtful when deciding who will fill our ranks.

Decades of rigorous research demonstrate that combinations of personal attributes can predict long term choices. Characteristics—such as gender, race, ethnicity, community of origin, and parental socioeconomic status—are associated with personal experiences of overcoming adversity and correlate with careers that address societal needs. 

Health care workforce diversity is a critical determinant of health equity

Despite commitments made to the principles of diversity, equity, and inclusion, US medical schools fall short of achieving racial-ethnic or socioeconomic representation of the general US population among their student bodies. While race-conscious admissions policies are now prohibited as a matter of federal law many, if not most, medical schools have implemented holistic reviews of applicants. This is a mission-aligned selection processes that takes into consideration the “whole” applicant, including how they would contribute to the learning and practice environment and what career choices he or she might make. 

Who “deserves” to be a physician? We need to learn from history

Try this experiment. Ask anyone hailing from a culture (like mine) that reveres the medical profession, “How much pressure were you under to go to medical school?” There is often a lot of pressure! Access to medical education is seen as a social good in and of itself, besides being highly valued by applicants, their families, and their communities. It is a path to economically security and a high social status career. Some medical schools explicitly embrace a responsibility for providing an avenue for intergenerational social mobility as part of their social mission, and many applicants are highly motivated to seek admission to medical school as a way out of poverty or as a path to an “American way of life” for immigrants. 

As historians, economists, epidemiologists, and sociologists have elucidated, there have been many structural barriers keeping certain, identifiable groups out of medical education. Despite being very proud of our tradition of social mobility, American medical schools have a long and inglorious histories of socially-sanctioned discrimination by gender, religion, and race. 

Things have improved, but there is still room for improvement. Images from each medical school class at MCW and our predecessor institutions line the main floor hallways. A quick study of these photographs confirms that the number of women and underserved minority graduates began to increase only in the most recent decades. 

As a matter of social justice, we make commitments to provide pathways to educate individuals from communities historically excluded from higher education and the professions by investing in “pipeline” programs.

Continuing to educate the economically privileged, well-mentored, and informed students is easier and less costly in the short term. But successful strategies to address access to health care and disparities in health outcomes, as well as access to careers in the health professions, require significant long-term investments and a willingness to innovate and enliven current practices. Among many other things, this will include selecting students from communities that struggle with healthcare needs, locating programs in such communities, providing trainees with significant exposure to primary care settings, ensuring a robust social determinants of health curriculum, and ensuring social accountability and public service across the institution. 

UC Davis has shown that best practices can align admissions with social mission 

The medical school at University of California at Davis—a state where race conscious affirmative action has been illegal since 1996—is an exemplar of a school with a comprehensive mission-based admissions process. This school has accomplished unprecedented student body diversity, socioeconomically (35% qualify for the AAMC Fee Assistance Program, for example) and in race and ethnicity (55% of students are from groups who are underrepresented in medicine). They have done so by investing in significant outreach and recruitment and by using rigorous data-based strategies, including a socioeconomic disadvantage score which systematically assigns a value to a student’s lived experiences of economic or educational disadvantage as a proxy for grit, resilience, and perseverance, balancing these indicators of success as physicians with the traditional academic performance data. 

In addition to these alternative metrics, these schools use structured approaches to interviewing applicants (e.g., multiple mini-interviews) which have been demonstrated to be less biased and have proven to be predictive of success in clinical settings. They work closely with local colleges and academic enhancement programs. They support community-based pre-health initiatives and integrate otherwise siloed pathways to health professions programs. Through this coordinated and deliberate suite of approaches, UC Davis is more likely that other schools to educate physicians who will commit to serve their home communities. In this way, they fulfill their stated social mission.

Medical College of Wisconsin has made generational investments to attract students who will address our social mission

Tackling complex long standing challenges such as health disparities and poverty require sustained effort and a long-term outlook. At MCW, under the leadership of President and CEO John Raymond and Julia A. Uihlein, MA, Dean of the School of Medicine, Provost, and Executive Vice President Joseph Kerschner, we have made significant investments to boldly align our medical school’s practices with a bold social mission. For example:

MCW is committed to increasing its impact in Wisconsin’s rural regions:

With robust community collaboration, we have built two regional campuses, MCW-Central Wisconsin in Wausau and MCW-Green Bay. At these campuses, centered in communities with severe health care access challenges, the admissions policies and practices are in place to attract and select a class that will be motivated and educated to serve the community. Admissions procedures meaningfully involve community representatives, there is significant community outreach, and pipeline programs and highly innovative medical school curricula are tailored to ensure that a high proportion of graduates will want to serve as generalist physicians in these rural areas where the need is stark and projected to worsen. 

MCW is committed to increasing its impact in Wisconsin’s urban regions:

MCW is partnering with the Greater Milwaukee Foundation, in the Thrive On Collaboration, to restore, repurpose, and anchor the former Gimbels-Schuster’s building on Martin Luther King Boulevard. Situated at the intersection of three urban neighborhoods on the North side of Milwaukee (Halyard Park, Harambee, and Brewer’s Hill), this “place based” investment focuses on bringing economic, social and health benefits to communities that struggle with significant health disparities. When the building opens, within the next year, hundreds of MCW faculty, researchers, staff, and students (including representatives of the Kern Institute) will take up residence in the building and conduct highly engaged community work, including medical student education and pipeline programs. In collaboration with the Dean’s Office and the Thrive on Collaboration, the Kern Institute is building a Health Equity Scholars Program for medical students committed to careers that address health equity (more to come!). 

Did you catch our vision? 

If medicine is to be equally effective and responsive to all people, regardless of where they live, who their parents are, or what they have, we have to change who becomes a physician and how they are trained. That is ingrained in the mission of the Kern Institute. Medicine, one of the oldest professions, needs to be socially accountable by engaging in regular self-examination. 

We must innovate, implement, and continuously update meaningful, substantive policies and practices that make measurable changes for the people we educate and in the lives of the people we pledge to serve with caring and character for generations to come. 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.