AMA Journal of Ethics^®

Abstract

This commentary in response to a case considers how merit and features of medical school applicants’ dossiers should be drawn upon in admissions processes to promote equity and inclusion in medicine. It is argued that medical schools should incentivize inclusion by redefining merit in their admissions goals and processes, promote meaningful inclusion, and show institutional leadership in addressing social justice.

Case

UMed is a public institution in a state with limited racial and ethnic diversity. Its largest funder is the state, and its mission is to train physicians to serve its residents. UMed’s recently appointed admissions dean has made new scholarships available to members of groups underrepresented in medicine (URiM). A primary funding source for these new scholarships is a pool of money that has traditionally supported only need- and merit-based scholarships. Decisions about which scholarships are offered to incentivize selected applicants to matriculate at UMed are made by its admissions committee.

Few in-state applicants from groups URiM reside in the state, so many new scholarships are awarded to out-of-state applicants. Some UMed deans and faculty oppose this trend, suggesting it’s unfair to reduce numbers of need- and merit-based scholarships and supposing that “they won’t stay here after they’re licensed.”

Commentary

Traditional medical school merit-based criteria largely consist of applicants’ grades, Medical College Admission Test^® (MCAT) scores, research engagement, scholarly article publications, mission trips, and clinical shadowing opportunities.¹ However, traditional merit-based criteria do not measure students’ structural competency.¹ These metrics often reflect better access to preparatory resources and the wherewithal to allocate time and energy to academic pursuits rather than competing psychosocial demands. As Ziegelstein et al note, schools pursuing merit scholarships often favor the affluent, which may be subverting our desire to bring in a broader socioeconomic and diverse class.² This article argues that medical schools should redefine merit in their admissions goals and processes to promote meaningful inclusion.

Structural Competence as Merit

For schools to address health equity and select structurally competent candidates, the definition of merit must align with schools’ missions.¹ A structurally competent candidate would combine identity and experience (eg, by being the first in their family to attend college or medical school, experiencing multigenerational influences, having undergone individual or historical trauma or socioeconomic deprivation) in ways that equate to structural competency.¹ In essence, the definition of merit should be expanded to what one has done with what one was given.³

The challenges students face can be severe. Speaking as a former applicant who faced such challenges, the third author states:

Those of us (who) have little financial support from our families can only succeed if we are able to eat and have a place to live. For a lot of us, homelessness and hopelessness are not so far away, and COVID-19 has exacerbated the struggle our families are experiencing…. Something that costs a penny more than what you have is prohibitively expensive when you don’t have it.⁴

Diversity of representation on its own, without meaningful inclusion or equity, does not motivate diversity of thought and understanding.

In some ways, scholarships and financial aid quantify the value placed on diversity or on an individual student. The second author has described her experience this way: “When I’m presented with a scholarship, I view that as the school seeing me, seeing my potential, and I don’t take that lightheartedly … and then I’m more empowered to do good and become involved and leave the school a better place than how I found it.”³ Students from minority and underserved communities bring with them life experiences and diverse perspectives that enhance the learning environment during medical school, and there is growing evidence that clinicians whose diversity reflects that of the communities they serve provide better care to underserved patients as well, improving patient outcomes.⁵

Equity

Equitable allocation of resources and opportunities is key to URiM students’ success and to equality of outcomes.⁶ The second author notes: “when schools provide merit scholarships and other incentives, URiM students know they are equitably entrusted with opportunities others with power and privilege simply expect.”⁴ Despite academic institutions’ mission statements and good intentions, students of color compose an inequitably small number of medical school matriculants.^6,7 The Association of American Medical Colleges (AAMC) notes that URiM students make up the largest proportion of students needing financial assistance.⁸ Most of these students need significant financial support, as reflected in the second author’s observation that “scholarships are vital…. My family is not wealthy, some of my family members have lost their businesses and we have lost some of our family [to the COVID-19 pandemic].”⁴

Inclusion

Inclusion plays a central role in expressing an individual’s worth in close-knit hierarchical organizations, such as medical schools.⁹ Diversity of representation on its own, without meaningful inclusion or equity, does not motivate diversity of thought and understanding. As the AAMC notes, inclusion requires “a climate that fosters belonging, respect, and value for all.”¹⁰ For instance, scholarships are only the first step in making students feel appreciated and accepted, with an authentic sense of belonging.^3,9 Paradoxically, scholarships allocated specifically on the basis of students’ URiM status could undermine efforts to foster students’ sense of inclusion. Redefining merit and expanding merit-based scholarship eligibility would place explicit value on students’ life experience, grit, and resilience—traits that support learners’ success. Inclusion can and should also be fostered by institutional investment in strong, effective support systems (eg, pipeline and pathway programs that encourage youth to consider medicine as a career, mentorship, role modeling by diverse faculty, academic resources, and health and wellness programming that can help students who have experienced personal or historical trauma). An ethos of cultural humility also creates space for shared inquiry and dialogue in communities of learners.

Institutional Leadership

Social justice requires responding to inequity based on gender, sexuality, race, ethnicity, religion, age, and other characteristics and requires that all individuals have access to quality care.¹¹ Medical schools’ positions of status in higher education mean they are well positioned to promote social justice by increasing representation of URiM students in medicine, expanding health equity content in curricula, and enhancing URiM students’ access to role models and mentors who have professional and life experiences similar to their own. Medical education administrators and faculty have duties to foresee the health implications of inequity in our shared society.¹² With deliberate and strategic planning, medical school leadership can motivate social justice in classroom- and clinic-based settings. Doing so demands faculty leaders with knowledge, intuition, influence, and courage who can inform both students’ understanding of how our shared past situates the quality of our present-day clinical encounters and the future role of public health in achieving social justice.

Given the recent national and global awakening to persistent, insidious effects of systemic racism, many institutions have been reviewing their missions and revising them to more robustly express diversity and inclusion. Yet most schools continue to struggle to achieve diversity in their student bodies or faculty.⁶ Internal pressures and structural biases maintain the status quo.¹² Accreditation bodies should play key roles in holding institutions accountable to their mission statements and in reaffirming fiduciary and social contract obligations of students, trainees, physicians, and medicine as a profession to serve patients and communities justly.

Leaders throughout an organization, especially those administering admissions procedures, can promote transformation and needed change. Typically standing committees in medical schools, admissions committees are independent and should be free of external influences. Internal influences, such as explicit—or, more often, implicit—biases must be acknowledged and uprooted from standing committee operations.⁷ Admission committee chairs must champion diversity, equity, and inclusion through deliberate and sustained effort lest they be remembered as barriers to progress.