Medical schools focus on boosting diversity, with challenges

NYU School of Medicine shook up the healthcare community last August when it announced that it would offer free tuition to all students. 

It was the first major medical school to do so and Kaiser Permanente School of Medicine, which will open next summer in Pasadena, Calif., followed suit in February with a similar offering for its first five classes. 

A principal driver behind NYU’s decision was to attract a more diverse group of applicants. Cost and the fear of large medical debt would no longer be a deterrent for students thinking about going to medical school, said Dr. Rafael Rivera, associate dean for admission and financial aid at NYU.

“We have been doing what people have proposed we do for many years—offering financial aid and resources to those who had the highest amount of demonstrated need. But despite that, we weren’t keeping up with the need,” he said. 

Lower- and middle-income students were still experiencing the brunt of the debt that continues to rise. “The system wasn’t working,” Rivera said. Tuition at NYU is $55,018 for the 2018-19 academic year and it increases by about 3% each year.

Additionally, students in the class of 2018 graduated from NYU with an average medical school debt of $167,988. NYU projected that the current first-year class will graduate with an average medical school debt of $81,827 and that about 30% of students will have medical school debt.

The offering will run NYU—which is using endowment funds to cover the costs—an estimated $600 million to maintain long term. The school has been raising funds for this for about 11 years.

Kaiser estimated that tuition will cost about $55,000 a year. The school plans to rely on money it spends on free tuition as part of the not-for-profit health system’s broader portfolio of community-benefit activities. 

Since the announcement last summer, NYU has seen a substantial increase in the number of students from lower socioeconomic backgrounds and minority populations applying to the school. 

NYU received nearly 9,000 applications for the 102 spots in the 2019 incoming class. Compared with last year, the applicants represent a 103% increase in individuals applying who self-identify as disadvantaged, a 140% increase in the number of black applicants and a 40% increase in Pell Grant recipients. 

“The accepted pool that we have thus far reflects increased diversity in socioeconomic status, which is an important facet of diversity in the physician workforce that hasn’t gotten the attention it deserves,” Rivera said. 

Of NYU’s 561 currently enrolled students, 45 are black and 30 are Latino; there are no Native American students, according to data from the Association of American Medical Colleges.

Although NYU’s experiment is unique, most medical schools throughout the U.S. have changed their admissions process in recent years or invested in pipeline programs to try to attract a more diverse pool of applicants. It’s part of a growing recognition across the industry that a more diverse physician workforce improves patient care and outcomes. And yet, the needle to increase the number of underrepresented minorities in medicine has hardly budged.

From 2014 to 2018, the percentage of black students enrolled in medical school rose from 6% to 7.12%, according to the AAMC. Additionally, Latino medical students increased from 5.3% to 6.4% of total enrollment while Native Americans still account for less than one-half of a percent of all medical students.

The continued marginal representation of black, Latino and Native American medical students likely stems from factors outside of a medical school’s control, said Norma Poll-Hunter, senior director of human capital initiatives at the AAMC. 

“A lot of it is based on larger societal issues,” she said. “Looking at black males in medicine, you can see the key issues—access to resources, racism, discrimination—and how that plays into a student’s trajectory.” 

The consideration of race in admissions is controversial, though. The Trump administration last July rescinded Obama-era guidance that encouraged universities to factor in race during their admissions process to increase diversity and replaced it with race-neutral standards. Considering race in admissions is currently supported by the 2016 U.S. Supreme Court decision Fisher v. University of Texas at Austin, but its future legality is precarious given recent appointments to the high court. 

Texas Tech University Health Sciences Center School of Medicine recently found itself in the crossfire of the debate, settling a 2004 complaint from the U.S. Education Department’s Office for Civil Rights by agreeing to explore “race-neutral alternatives” to increase diversity. The Office for Civil Rights argued that the school was violating federal law by inappropriately using race in its admission criteria. 

Some medical schools are finding ways to increase underrepresented minority students without considering race at all in admissions. 

For instance, Ohio State University College of Medicine has removed photos from applications and tried to mitigate the impact of individuals’ implicit bias. 

About 10 years ago, just a “handful of people” were reviewing thousands of applications to Ohio State, said Dr. Quinn Capers, associate dean of admissions. The school gets about 8,000 applicants each year for 200 seats.

“How holistic can you be when two or three people are reading thousands of applications?” he said.

Capers has since revamped Ohio State’s entire admissions process. Now about 80 faculty members—both physicians and researchers—review the applications. They weed out the bulk of them to get to a more manageable number for the admissions committee, which has 140 members, to review for interviews.

To address implicit bias, photos of applicants have been removed and the committee and screeners get yearly training on implicit bias and how to recognize it in oneself. 

They are also a diverse group. 

“Your admissions committee should reflect the class you want to see,” Capers said. “If you want half your incoming class to be women, half of your admissions committee should be women.” 

When it comes time to select candidates, Ohio State, similar to most schools, is following the holistic review process championed by the AAMC.

Holistic review involves assessing an applicant by looking at not only their grades and test scores, but their experiences and character by looking at things like volunteer experience, letters of recommendation and personal essays. Race and gender are not considered, Capers said.

“It’s about looking at the whole applicant,” said Geoffrey Young, AAMC’s senior director of student affairs and programs. 

The holistic review process values diversity of experience and background, Capers said. 

“It’s quite different from how admissions used to be,” he said. “If you weren’t a nice person or you didn’t have much community service in your application, you could get into medical school. It’s not like that anymore, we want well-rounded people.” 

Since the changes, Ohio State has increased the percentage of underrepresented minority students from 13% in 2009 to 25% in 2018. Capers said it only happened because Ohio State was intentional about increasing diversity. 

“I consider the lack of diversity in the physician workforce to be an emergency and we approach it like it’s an emergency,” he said. 

Pipeline programs are another way medical schools are trying to increase diversity. University of Illinois College of Medicine has had a pipeline program to attract more Latino students since the 1990s. 

For years, the work was funded through grants from the Centers of Excellence Program at HHS’ Health Resources and Services Administration. The grant wasn’t renewed in 2017, but UIC has continued the work, said Jorge Girotti, director of the Hispanic Center of Excellence at UIC. 

UIC exposes high school students to the sciences and then mentors college students pursuing a pre-med degree. They advise the college students on volunteer opportunities and preparing for tests so they are competitive applicants. 

About one-third of the students from the high school program are now in medical school. Girotti admitted the success rate is “modest.” Instead, the admissions office plays a bigger role in UIC’s effort to improve diversity. Nearly 17% of UIC’s current medical students are Latino, up from the 1990s when about 11% of students were Latino, Girotti said.

“We couldn’t rely on pipeline programming to have the kind of matriculation we want,” he said.