Medical School Admission Policies Disadvantage Low-Income Applicants

The Flexner Report, presented in 1910 by Abraham Flexner to the Carnegie Foundation, has been lauded as the turning point for medical education by imposing new qualifications at every training stage. ¹ The report sought to legitimize the medical profession by standardizing the foundation of education and priming future physicians to make scientific discoveries. It required university education before medical school to raise the academic standards of admission. Flexner emphasized the importance of this premedical coursework as critical to the foundation of medicine. The consequence of this shift in medical education, however, was that the same wealthy white men filled the seats of medical schools in the early twentieth century, because they were the only ones who could afford the prerequisite university education. Now, they at least had “qualifications,” according to Flexner, to learn the art and science of medicine.

Little has changed. In 2017, 24% of United States medical students had a family income in the top 5% of income earners. ² The percentage of medical students from families in the highest quintile of household income has not dropped below 48% since the 1980s, and the percentage of students from the lowest income quintile has never risen above 5.5%. ³ Although the total number of medical students graduating with debt has decreased in recent years, the average indebtedness has risen. Today, 110 years after the release of the Flexner Report, the standards put in place continue to inequitably exclude individuals who identify as low-income before and during the application process.

The Qualified Applicant Dilemma

Despite schools claiming that they are “need-blind” to a student’s financial situation at the application stage, every section of the application—from transcript, Medical Comprehensive Assessment Test (MCAT) scores, activities, and letters of recommendation—is associated with income. The primary application of the American Medical College Application Service itself reflects this focus by asking applicants how they paid for college, their history of residence in a medically underserved area, their receipt of state and federal assistance programs, their family income, their receipt of Pell grants, and disadvantaged status. ⁴ The reality of this complex admissions process is that many applicants from low-income backgrounds do not have an equal opportunity to become “qualified” because of structural barriers.

In an effort to differentiate between numerous qualified applicants, medical schools focus on standardized, quantitative metrics reflecting cognitive performance. These include the MCAT and grade point average (GPA), and a score difference of a few points can become a distinguishing factor. ^5,6 Despite being used to screen applicants at various stages of the admissions process, score cutoffs are rarely published in freely available sources, leading students to pay primary and secondary fees for schools where they are not competitive for admission. MCAT scores and GPA reflect a student’s ability to focus primarily on their studies, as well as access to tutoring and additional academic resources. Low-income students often work during the school year, leaving less time for schoolwork, attendance at office hours, and tutoring. They may be less able to pay for tutoring services, their own textbooks, or supplemental resources such as review books. Additionally, these time constraints pose a challenge to developing relationships with professors and others who might write letters of recommendation.

The MCAT may also be a financial barrier. Preparatory materials and tutoring for the MCAT can cost hundreds to thousands of dollars. MCAT scores are positively associated with income, and underrepresented students often demonstrate lower mean MCAT scores due to structural barriers, racism, and unequal opportunities. ⁷ Importantly, noncognitive performance, such as a student portfolio and multiple mini-interviews, are more strongly related to performance in a clinical setting, suggesting that they should weigh heavily in decision making rather than test scores or GPA. ⁸

Extracurricular activity involvement, such as shadowing, volunteering, and research, is a critical part of the application. Kahn and Sneed write that “Medical school admissions favors applicants whose physician relatives and access to money afford prestigious experiences and shadowing opportunities.” ⁹ Opportunity cost, work responsibilities, or lack of social resources may prohibit low-income and/or first-generation premedical students from completing as many unpaid activities as their peers from a higher socioeconomic status. ¹⁰ Low-income students may also have work or work-study commitments that limit their availability to participate in unpaid activities such as research, which are substantially correlated with completion of a science, technology, engineering, or mathematics degree. ¹¹ Additionally, 1 in 5 medical students has a parent who is a physician. ⁹ Students with family members in health care have increased access to clinical shadowing and volunteering opportunities, while low-income students often have less social capital. Training and enrichment programs exist for undergraduates who identify as being from an underrepresented racial, ethnic, or financial background (examples include the Premedical Urban Leaders Summer Enrichment Program at Cooper Medical School of Rowan University and the Sidney Kimmel Medical College Summer Training and Enrichment Program for Underrepresented Persons Medicine Program). These programs allow students to build professional connections, obtain clinical shadowing opportunities, and participate in research. Participation in summer enrichment programs is associated with an increased likelihood in application and matriculation to medical school, however substantial barriers to participation exist for low-income students as these experiences often do not offer financial stipends and present an opportunity cost of not being able to participate in paid employment during program participation. ¹²

In the past decade, the number of medical school applicants has steadily risen, and there is fierce competition for a relatively constant number of enrollment spots. ¹³ Students who struggled during their undergraduate coursework may view their grades as a barrier to admission, and face additional costs associated with postbaccalaureate programs designed to enhance their GPA. ¹⁴ Students with financial means may seek paid support for their personal statements, secondary essays, and interview preparation. The financial cost associated with applying has ballooned with applicants paying thousands in application fees, MCAT registration and preparation, and interview-associated expenses. ¹⁵ The cycle of increasing costs is perpetuated in part by the fact that, the more schools to which an applicant applies, the higher the likelihood of acceptance. Although the Association of American Medical Colleges’s (AAMC) Fee Assistance Program covers fees related to the first 20 primary applications and offers reduced fees for the MCAT examination, students must include parental income, even if they are financially independent, which disqualifies some applicants. The program does not cover the additional costs associated with interviewing such as professional clothing and travel.

Correcting for Income Inequality

To date, 3 main solutions have been implemented to recruit students from backgrounds underrepresented in medicine: 1) additional financial assistance; 2) pathway programs; and 3) holistic admissions. Fifty-five years after the Flexner Report, a study in the Journal of the American Medical Association identified an “untapped pool of possible medical school applicants,” who would need financial support to consider and pursue a medical career. ¹⁶ Institutions have gone about this several ways since, usually involving some combination of grants and loans. Schools offer financial aid under several models, most recently tuition- and debt-free aid. In tuition-free financial aid, no student is required to pay the tuition portion of the cost of attendance to the school. Meanwhile, debt-free aid takes into consideration the individual’s family and personal situation to provide a package that covers whatever portion was not going to be forgiven by financial aid. Some schools offer students institutional loans at lower interest rates or scholarships with various stipulations. Regardless, these forms of financial support fail to address earlier roadblocks for applicants.

Pathway programs support future applicants in an ecosystem of resources through education and mentorship and can ameliorate barriers associated with medical school applications for low-income applicants. For example, The Ohio State University College of Medicine Medical Careers Pathway Post Baccalaureate Program offers conditional acceptance to its medical school at the time of program completion. Thus, those who complete the program do not have to pay application fees or travel costs associated with medical school interviews. The program offers an MCAT preparation course and sets a passing cutoff for MCAT scores. Finally, as it a full-time program, students are eligible to apply for financial aid and receive a cost of living stipend. Successful applicants to combined bachelor of science or arts or doctor of medicine programs and early assurance medical school programs are often not required to take the MCAT examination for admission—evidence that the MCAT examination is not a necessary metric for admissions decisions. ¹⁷ Some have cited this as a reason to get rid of the MCAT entirely and reinvent holistic admissions. ¹⁸ Holistic admissions involves looking at the application in context of the applicant’s life, opportunities, and experiences when it comes to undergraduate institution, extracurricular activities, childhood environment, work history, and other characteristics.

When schools describe their process as holistic admissions, it is difficult to know how admissions committees control for the fact that many aspects of the application are affected by money, not to mention the applications that were never submitted in the first place for this reason. ¹⁹

Work is being done to address these limitations: the AAMC currently provides admissions committees with information about applicants in the form of indicators. These tags represent characteristics such as family income, urban or rural neighborhood, disadvantaged, low health access, or first-generation as a way of making it easier for committees to identify particular applicants and adjust for their life experiences. Therefore, admissions committees should clearly define what characteristics, consistent with the institution’s values and goals, should guide holistic evaluation of applicants while at the same time considering how these metrics may be affected by life experience. Doing so would guide committee members to actively keep this perspective in mind while reviewing a diverse applicant pool. Simplifying someone’s application is problematic to say the least, but it is likely that the same does not happen to individuals from wealthy backgrounds to adjust for what their resources have allowed them to do.

Admissions Reimagined

Before the Application

Short-term solutions will likely take the shape of trying to "level the playing field" for future applicants without the financial resources to otherwise prepare as a premedical applicant. First, a reduction in overall college debt accrued will help more potential applicants apply. ²⁰ More internships and summer programs that provide compensation or scholarships and recruit individuals from low-income backgrounds could be funded as a line in grant support applications. This way, students do not have to choose between participating in a career-enhancing opportunity and being financially stable. Free and low-cost examination preparation resources will continue to be critical for low-income students who cannot pay hundreds of dollars for flashcards, question banks, and preparatory courses. An example is the MCAT collection developed by the Khan Academy in collaboration with the AAMC, which provided free, short lectures about main topic tests on the examination; the accessibility of this particular resource is uncertain, however, the concept can serve as a model for what open access MCAT examination preparation could look like. Expanded financial aid programs, such as the Fee Assistance Program by the AAMC, would make applying to medical school a reality for many potential applicants. Such an expansion would need to recognize that potential applicants may be financially independent from their families and, thus, their family’s income should not be the only data point used to determine eligibility. Expanded fee assistance should also address other application-related expenses such as interview expenses, transcript fees, and secondary application fees. Lastly, schools can play an important role in removing barriers for low-income applicants by reducing or removing their secondary application fees and providing financial support to assist with interview expenses.

Selection Process

The primary responsibility for determining who will train as a physician in the United States falls on admissions committees of individual medical schools. Given this responsibility, committees need to update their policies and procedures to reflect not only institutional values but also correct for past injustices. This could take the shape of weighing more heavily portions of the application that demonstrate noncognitive performance as part of holistic review. Committees can work on educating members about different forms of bias and providing concrete tools and strategies for to mitigate bias when reviewing applications. These individuals must also be attuned to the bias known to manifest in letters of recommendation. ²¹ It is also important to recognize that the MCAT examination is not the only, nor the best, predictor of future success. Evidence for this can be seen in the performance of students who attend medical school through a combined 8-year BS/MD program or early assurance pathway programs, such as FlexMed at the Icahn School of Medicine at Mount Sinai; these students do not take the MCAT as part of their admission yet perform on par with their peers selected through traditional admissions. ¹⁷

Changing Perceptions

Changing perceptions about the “qualified applicant” begins with an acknowledgment of the structural barriers that continue to exist in preparing and applying to medical school. A shift in the perception of who will make a qualified, successful, and competent future physician that does not take the qualifications set out by the Flexner Report as dogma is a first step. Commitment from medical centers and other medical entities to their local communities will foster a diverse pool of applicants qualified based on their experiences and preparation rather than numbers on a page. This work will take effort on behalf of all of medicine: it is time to build the future of medicine around equity, rather than use money as a “doorkeeper” as the Flexner Report suggests.