AMA Journal of Ethics^®

Abstract

Over the past decade, holistic review has been implemented to motivate schools’ compliance with state and federal laws about how to regard race in admissions processes and decisions. From clinical, ethical, and public health standpoints, physician workforce diversification is widely regarded as foundational to medicine’s capacity as a profession to respond justly to the health care needs of a pluralistic nation. In response to a case, this commentary considers merits and limitations of holistic review’s roles in advancing health professional workforce diversity and health equity.

Case

U School of Medicine’s mission is to train physicians to serve residents of the state who are recognized by the state’s health department as medically underserved, which is defined in terms of inequitable health outcomes in communities inhabited predominantly by people with racially and ethnically minoritized identities. Over half of the state’s population resides in these communities, which are both rural and urban.

Accreditation standards compliance requires schools to define diversity categories, which, for U, includes students from resource-poor families, women, African Americans, Latinx Americans, Native Americans, and first-generation college graduates. U’s admissions committee members holistically review candidates using a rubric that includes applicants’ diversity categories, academic performance, service history, life experience, and communities of origin.

U admissions committee members deliberate about to whom, from their alternate list, they should offer admission into next year’s class. U’s usual protocol for drawing on the alternate list is for a subcommittee to determine which alternates will be invited to fill the class. Subcommittee members generally agree that matriculants who have already accepted U’s offer of admission are, collectively, well-balanced among rubric categories, except for race. One alternate is a first-generation college graduate from a rural, underserved, resource-poor area of the state. Another, from a suburban community, is a racialized minority group member whose parents are both physicians. One has a better academic record than the other, but the 2 candidates’ overall rubric scores are nearly identical. Subcommittee members deliberate about which candidate should receive one of U School of Medicine’s last offers of admission.

Commentary

We are at a moment of national reckoning over the racial and social injustices that have plagued us since the formation of this country. Given the inequitable negative effects of the COVID-19 pandemic on communities of color in the United States, as well as the murder of George Floyd and other Black individuals at the hands of police and the Black Lives Matter protests that were sparked by these deaths, systemic racism—in particular, anti-Black racism—is being acknowledged at a level never previously reached in recent history. Many institutions, including those in health care and academic medicine,^1,2 have recently expressed their commitment to building an ant-racist future, and it is important at this moment to think strategically about how to advance both justice and diversity in medical education.

Medical school admission represents a gateway to the profession of medicine. Consequently, the medical school admissions process is a highly visible stage upon which evidence of disparities due to systemic racism and inequalities manifest. Blacks and Hispanics, for example, continue to make up a smaller percentage of both applicants and matriculants than their share of the US population,^3,4,5 and roughly 75% of medical student matriculants come from families in the top 40% for household income.⁶ Matriculants’ lack of racial and socioeconomic diversity reflects inequalities embedded deeply in economic, social, and educational institutions that lead to diminished opportunities for students from underrepresented minority groups to enter medicine.

Over the past decade, holistic review in medical school admissions has been introduced and widely disseminated as a practice to increase diversity in medical schools.⁷ The Association of American Medical Colleges (AAMC) refers to holistic review as “mission-aligned admissions or selection processes that take into consideration applicants’ experiences, attributes, and academic metrics as well as the value an applicant would contribute to learning, practice, and teaching.”⁸ This case illustrates how holistic review can be implemented in medical school admissions. How does holistic review work in practice, and how effective is it in advancing diversity and social justice in medical education admissions? In order to answer these questions, it is critical to understand the principles of holistic review in admissions as well as the legal opinions on which holistic review in admissions is based.

Holistic Review

The landmark Supreme Court case Regents of the University of California v Bakke (1978) has formed the basis for admissions policies in higher education institutions for over 4 decades.⁹ In this case, the Supreme Court outlawed racial quotas in admissions by declaring unlawful the University of California, Davis School of Medicine’s practice of reserving spots for minority students who were evaluated under different standards through the school’s “2-track” admissions policy. At the same time, the court effectively made affirmative action permissible under some circumstances by striking down a lower court’s ruling that had prohibited the university from taking race into account as a factor in its future admissions decisions. The court was deeply divided on this case; both rulings were decided by a 5-4 vote, with Justice Lewis Powell’s vote determining the majority for both rulings. Yet of the 6 separate written opinions that were included in the court’s decision, Justice Powell’s opinion in the Bakke case has been the argument upon which higher education institutions have subsequently based their diversity efforts in admissions.¹⁰ Justice Powell found it permissible for universities to consider race in admissions on the grounds that diversity was essential to the educational mission of the institution. He wrote that the attainment of a diverse student body “clearly is a constitutionally permissible goal for an institution of higher education”¹¹ and that the university was “seeking to achieve a goal that is of paramount importance in the fulfillment of its mission.”¹¹ In medicine, specifically, he recognized the value of diversity in allowing the profession to ultimately fulfill its mission to serve a diverse patient population. In his written opinion, Justice Powell also elaborated on what an admissions system that supported diversity could look like. He identified race and ethnicity as factors to consider among many other qualities, such as life and work experiences, leadership potential, communication skills, and compassion. He wrote:

An admissions program operated in this way is flexible enough to consider all pertinent elements of diversity in light of the particular qualifications of each applicant, and to place them on the same footing for consideration, although not necessarily according them the same weight. Indeed, the weight attributed to a particular quality may vary from year to year depending upon the “mix” both of the student body and the applicants for the incoming class.¹¹

Holistic review in admissions advances equality, not necessarily equity.

With these words, Justice Powell presented most of the core principles upon which holistic review in medical school admissions was established. The AAMC Holistic Review Project defines holistic review as “a flexible, highly-individualized process by which balanced consideration is given to the multiple ways in which applicants may prepare for and demonstrate suitability as medical students and future physicians.”⁹ Under the holistic review framework, institutions are instructed to utilize rubrics to evaluate candidates consistently and equitably based upon a broad mix of key experiences, attributes, and academic metrics (EAM) that are prioritized by the committee to best reflect the institution’s mission. In holistic review, applicants are evaluated on the basis of the value they might contribute to the institution’s learning environment as well as to the institutional mission. Where allowed by state laws, admissions committees may consider race and ethnicity as part of the broader mix of applicants’ key EAM for the purpose of holistic review. While racial quotas and racial balancing practices are prohibited, admissions committees have flexibility to “weigh and balance” the range of criteria needed,⁸ including race or ethnicity, to create a diverse class each year that will allow the institution to achieve its desired educational goals.^8,9,12 It is important to note that 8 states have prohibited considerations of race, ethnicity, and sex in public higher education admissions practices.⁹ For public medical schools in these states, holistic review must utilize race-neutral policies and practices.⁹ Holistic review also demands an evidence-based approach in which institutions evaluate their admissions process to ensure that it ultimately yields students who support the mission of the institution.

Let us apply the AAMC’s framework for holistic review in medical school admissions⁸ to the case of U School of Medicine. The school has established broad-based screening and selection criteria that are linked to the school’s mission to train physicians to serve medically underserved residents of the state. The desired EAM are presumably based upon local performance data that can be used to assess a student’s likelihood of fulfilling the school’s mission. The fact that the final 2 applicants have very different EAM but are nearly identical in their rubric scores suggests that the holistic review process is capable of generating a diverse candidate pool. Assuming it is permissible under state law, the school may consider race and ethnicity, among other diversity factors, in its deliberations—not to create a racially balanced class but to achieve the class diversity the school believes will enable it to fulfill its mission and optimize learning environments.

Holistic Review Advances Equality, Not Equity

Holistic review aims to increase diversity in admissions by threading the needle through the legal landscape that was first established by Powell’s opinion in Bakke and upheld in subsequent Supreme Court rulings concerning affirmative action (Grutter v Bollinger, 2003; Gratz v Bollinger, 2003; Fisher v University of Texas, 2013 and 2016).¹² The AAMC holistic review framework instructs medical schools to tailor their diversity efforts and goals to their institution’s mission.⁹ While this framework has allowed medical schools to advance the legitimate argument that diversity is essential to excellence and to meeting the social contract of the profession of medicine to care for the health of a diverse nation, it is also important to understand the arguments that have not been advanced since Bakke. In his written opinion, Justice Powell specifically rejected UC Davis’ argument that its special admissions program served the purposes of reducing the historic underrepresentation of minorities in medical school and countering the effects of societal discrimination. However, Justices William Brennan, Byron White, Thurgood Marshall, and Harry Blackmun, who voted with Justice Powell to allow for the consideration of race as a factor in admissions, broke with Powell’s opinion in their separately written opinion on the Bakke ruling:

Davis’ articulated purpose of remedying the effects of past societal discrimination is, under our cases, sufficiently important to justify the use of race-conscious admissions programs where there is a sound basis for concluding that minority underrepresentation is substantial and chronic, and that the handicap of past discrimination is impeding access of minorities to the Medical School.¹¹

The 4 justices thus argued that deliberate race-conscious policies were actually necessary to undo the effects of systemic race-based discrimination. This stance diverges from the current practice of holistic review, which eschews goals explicitly related to social justice and instead seeks to advance diversity through institution-specific education missions.^8,12

The arguments that the 4 justices offered for race-conscious admissions to mitigate historical racism and discrimination deserve renewed consideration at this historic moment when there is a loud call within academic medicine to dismantle systemic racism. Holistic review in admissions is a well-intentioned, thoughtfully constructed, yet ultimately limited tool that has failed to yield a racially and ethnically diverse physician workforce. Morris et al’s recent study demonstrates that the proportion of Black and Hispanic male matriculants has changed little in the 4 decades since the Bakke ruling. In fact, during this time, the percentage of Black men enrolled in medical school actually dropped from 3.1% of the national medical student body in 1978 to 2.9% in 2019.¹³ Holistic review in admissions is limited in its ability to produce a racially diverse physician workforce precisely because it is based on Powell’s argument that diversity should be sought because it benefits all, not because it can benefit some who have been most victimized by past discrimination. Accordingly, holistic review in admissions advances equality, not necessarily equity. Justice Blackmun’s separate written opinion in the Bakke case was prescient in this regard. He wrote: “In order to get beyond racism, we must first take account of race. There is no other way. And in order to treat some persons equally, we must treat them differently.”¹¹

Improving Workforce Diversity

The medical schools most successful at increasing physician workforce racial diversity have missions that specifically focus on access and opportunity for students from underrepresented groups. Rodriguez et al reported that, between 2003 and 2013, historically Black college and university (HBCU) medical schools made up 2.4% of medical colleges yet accounted for 14% of Black medical school enrollees.¹⁴ The CUNY School of Medicine, while not an HBCU medical school, is similarly mission-driven and focuses on increasing access for students from historically underrepresented groups in medicine so that they can pursue medical careers and ultimately care for medically underserved patients and communities. This mission drives the school’s holistic review process and has resulted in students from underrepresented groups in medicine making up 46% to74% of the entering class every year since the creation of the new 7-year BS/MD program in 2013 (A. Motta-Moss, PhD, unpublished data, 2019, and J. Erves, email, July 8, 2021). The AAMC recognizes access- and opportunity-focused institutional missions as another legally justifiable strategy by which race-conscious admissions practices may be implemented: “the door remains open for medical schools to incorporate core access and equal opportunity principles into their enrollment-related policies, particularly as they address issues of critical access to high-quality health care that are so central to the schools’ mission-driven aim.”⁹

Despite the limitations of holistic review, efforts are being made to stretch holistic review practices to address structural racism and its impact on the admissions process in medical schools. The simultaneous COVID-19 pandemic and protests against systemic anti-Black racism during the past year have created a heightened awareness of the impact of external experiences— such as historical, political, and social events—on applicants’ EAM. The AAMC’s Advancing Holistic Review Committee recently released guidance documents to help admissions committees consider the disparate ways that these events have affected applicants and to provide guidance on processes, policies, and resources that institutions can implement to mitigate the adverse effects of these events on applicants.¹⁵

Conclusion

Holistic review alone is not sufficient to create a physician workforce whose racial composition corresponds to the racial composition of the US population. However, it does prompt medical schools to ask whether an institution’s mission explicitly addresses diversity and health equity; whether the EAM prioritized by an institution’s admissions rubric generate admission offers to applicants who motivate the institution’s mission; and whether deliberation about each applicant addresses that applicant’s qualities within historical, social, and political context to promote equity. With these foci on justice, institutions can meet their diversity goals and fulfil their social contract with society.