On October 31, 2022, the Supreme Court heard oral arguments in cases involving Harvard University and the University of North Carolina that center on the use of race-conscious approaches in undergraduate admission policies.
The Court’s decisions on these cases could result in the elimination or severe restriction of the already limited use of race as a consideration in admission decisions.
The experiences of institutions in which race-conscious admission policies have already been eliminated suggest that this could result in a substantive decline in students of Black race or those of Hispanic or Latino ethnicity attending major colleges and universities.1 These Supreme Court cases focus specifically on undergraduate admission policies.
There is, however, concern that reversing or restricting the use of race and ethnicity in academic admission policies could also threaten the diversity of medical schools, both directly by restricting race consciousness in medical school admission practices and indirectly by reducing the overall number of minoritized undergraduate students attending US colleges and universities who could apply to medical school.
The Supreme Court’s precedent regarding race-conscious admission policies rests on the notion that it is both important and within the purview of schools to ensure diversity of viewpoints and experiences among students.
In the words of Justice Lewis F. Powell Jr, author of the controlling opinion in the Court’s landmark 1978 Regents of the University of California v Bakke decision,2 “the nation’s future depends upon leaders trained through wide exposure to the ideas and mores of students as diverse as this nation of many peoples.”
The value of diversity was echoed in the Court’s 2003 decision in Grutter vs Bollinger,3 wherein Justice Sandra Day O’Connor, writing the court’s majority opinion, stated that the law allows for “narrowly tailored use of race in admission decisions to further a compelling interest in obtaining the educational benefits that flow from a diverse student body.”
The compelling interest in racial and ethnic diversity in medical education is unequivocal. Diversity in medical education enhances the educational experience that medical schools can offer all students. Students who train at medical schools that are more diverse have been shown to be more comfortable treating patients from a wide range of backgrounds, including Medicaid and uninsured populations.4
Physicians are obligated to treat persons from all walks of life compassionately and equitably, and training with diverse peers prepares medical students to meet that challenge better than training in homogeneous environments.
In addition, converging evidence demonstrates that, by increasing available viewpoints and intellectual perspectives, diversity improves the cognitive performance and productivity of teams in a wide range of disciplines.5
This is an important consideration because the pedagogical model of many medical schools involves highly interactive team-based learning and problem-solving, an approach that resembles how physicians practice medicine. In short, focusing on diversity is likely to enhance the overall quality of learning in medical school.
Diversity in medical school is the pipeline to a diverse physician workforce, which in turn is essential to serving an increasingly diverse populace. In a country saddled with vast, persistent racial disparities in health access and outcomes, physicians who belong to minoritized racial and ethnic groups are far more likely to work in medically underserved areas and are more likely to enter primary care fields.4
In addition, patients who belong to racial and ethnic minority groups report having more positive experiences with race-concordant physicians.6 Racial diversity in medical schools is thus critical to promoting care for the most underserved segments of the patient population and providing patients from these populations with their preferred caregivers.
Racial and ethnic diversity in medical education cannot be achieved without an intentional and sustained focus on increasing the number of persons from minoritized backgrounds. Despite long-standing efforts to improve diversity in medicine, individuals of Black race or those of Hispanic or Latino ethnicity remain highly underrepresented. In fact, relative to the increasing diversity of the US population, the representation of physicians from racial and ethnic minority groups has been decreasing over time.7 If colleges, universities, and medical schools are mandated to use race-neutral admission policies, medical schools will need to take innovative and decisive steps to ensure increased diversity.
Medical educators should use this potentially pivotal moment to take stock of which applicant qualities predict excellence as future physicians and recognize that these qualities are well represented among applicants from racial and ethnic groups that are underrepresented in medicine. To that end, medical schools should evaluate applicants using a holistic, individualized approach8 that accounts for personal strengths and a candidate’s metaphorical distance traveled. For many persons from minoritized communities, inclusive evaluation will reveal obstacles they have overcome to achieve the same academic milestones that their peers may have achieved without facing similar adversity. In addition, medical schools should consider prior work related to ameliorating health disparities and social inequities as strong positive factors in applicants to medical school. Not all persons who face these challenges are from minoritized groups, but these issues resonate with many medical school applicants from underrepresented groups and are as germane to the job of practicing medicine as participation in laboratory-based research, which medical schools have traditionally viewed positively with respect to medical school admission policies.
In considering which applicant qualities define excellence, medical schools should also carefully evaluate how they are using standardized tests and other traditional metrics of achievement. Many qualities such as compassion, empathy, commitment, curiosity, resilience, and altruism are essential to practicing medicine, but whether a person has these qualities cannot be determined based on a Medical College Admission Test (MCAT) score, a grade point average, or an undergraduate education at a prestigious institution. Although it is appropriate to use MCAT performance as a threshold measure to identify applicants who are prepared to perform adequately in preclerkship medical school courses, pegging the reputation of medical schools to students’ high MCAT scores and then using those scores to stratify otherwise highly qualified candidates is tautological. This use of MCAT scores also disadvantages talented (and often underrepresented) students of limited means who lack resources for review materials, courses, and tutors and does not account for the personal characteristics that make for a good physician.
Race-neutral admission policies are not the same as admission policies that fail to recognize and value experiences of disadvantage on the part of applicants. Because racial and ethnic disparities in the US are both systemic and profound, holistic admission policies that address representation from a variety of other disadvantaged backgrounds would have a positive effect on persons who belong to historically marginalized racial and ethnic groups. For instance, because average households of Black race or those of Hispanic or Latino ethnicity in the US earn about half as much as the average White household and own only about 15% to 20% as much net wealth, programs that attract learners from low-income backgrounds to medical schools are likely to disproportionately support applicants of Black race or those of Hispanic or Latino ethnicity.9 However, medical schools disproportionately enroll students who are from high-income households, even among students from underrepresented racial and ethnic groups.10 Admission policies that target factors like socioeconomic status may not offer advantages to persons from minoritized populations who have other privileges (eg, wealth, elite education), but if the policies are well designed, they will benefit students who are most negatively affected by the many structural disadvantages associated with their identities.
In addition, medical schools should anticipate that there may soon be fewer minoritized applicants from the most elite undergraduate institutions in the US. If race-conscious admission policies are discontinued at the most highly sought-after schools in the US, some students who would have attended those institutions will matriculate at less coveted, but nonetheless highly rigorous schools. Medical schools may need to start looking toward institutions they may not have previously considered as sources of applicants. Furthermore, in the face of declining applicants of Black race or those of Hispanic or Latino ethnicity, medical schools may need to establish partnerships with undergraduate institutions to develop pathway programs that prepare underrepresented premedical students to become competitive medical school applicants. For undergraduates at the University of Pennsylvania, these efforts take the form of the Johnson Scholars program at the Perelman School of Medicine, which is a longitudinal mentorship experience. Another program, the Penn Access Summer Scholars, is open to students attending 5 historically Black colleges and universities (Howard University, Morehouse College, Oakwood University, Spelman College, and Xavier University), Bryn Mawr College, Haverford College, Princeton University, and the University of Pennsylvania.
Health and health care in the US are not race neutral, and medical students must be trained to navigate a profession that is heavily influenced by issues of race. Advancing racial diversity in medical schools is critical to achieving this objective. If practices that promote racial diversity in admission policies are eliminated, medical educators must rise to this challenge with a flexible but firm commitment to creating diverse learning environments that continue to provide the best education for students and ultimately the best care for patients.
Article Information
Corresponding Author: Roy H. Hamilton, MD, MS, University of Pennsylvania, 518 Goddard Laboratories, 3710 Hamilton Walk, Philadelphia, PA 19104 (roy.hamilton@pennmedicine.upenn.edu).
