Let’s level the field!

Medical schools have made great efforts and important strides in becoming more inclusive.  Nevertheless, the physician workforce of the United States does not yet reflect the racial/ethnic composition of our country.  Many factors undoubtedly contribute to the underrepresentation of black, Hispanic, and American Indian physicians.  Ethnic underrepresentation may in part be a proxy for low income status; ethnicity, income, and parental education all correlate in the US.  A recent “Analysis in Brief” by the AAMC shows that 3/4 of all medical school matriculates come from the top two household-income quintiles and that this distribution has been unchanged for 3 decades.  As income stratifies even more in the US and our population becomes more diverse, we must consider approaches beyond those employed and contemplated in the last 30 years.

As medical schools consider how to increase representation, they may partially have overlooked the process and expense involved in the application and matriculation to medical school.   In addition to discouraging successful application to medical school by low income students, an expensive or unclear process may especially discourage lower income students from seeking placement at very selective medical schools, leading to what is termed “undermatching” in undergraduate education.

There are simple steps that universities preparing medical students and medical schools themselves could take that could address some of this unintended financial bias.  My perspective on this issue arises from years as a Biology faculty member, advising hundreds of premedical students, as a university leader, and as the father of 3 recent (successful) applicants to medical school.  Let’s examine the application process stepwise to identify potential improvements.  I will focus on the schools that use the AMCAS application system, the majority of US medical schools.

              According to AAMC (https://www.aamc.org/data/facts/applicantmatriculant/) data, non-white applicants and matriculants to US medical schools have lower GPAs and lower MCAT scores than white (and generally wealthier)  applicants.  A large percentage of wealthier students are using MCAT prep services, financially inaccessible to lower income families.  Universities should consider whether test preparation is something that they should do at reduced cost in a more extensive and intentional way.  Additionally, if such courses were offered for credit within a degree program, financial aid could be applicable.  Test prep materials could be a target of OER (open educational resource) development, as well.  The financial playing field may never be level, but it need not be quite so steep a hill.

              The MCAT test itself costs $315 for a single administration, but the AMCAS Fee Assistance program reduces that and the costs of application significantly.  To qualify for Fee Assistance, a family of 4 in the contiguous US would need an income below $73,800; fortunately many applicants would be eligible for this assistance as it aligns with the upper end of the third economic quintile.  In such cases, cost is reduced to $125 and students receive access to preparation materials and other support.

The cost of application can also be a barrier.  Again, the Fee Assistance program is a major help.

AMCAS supports free application in the case of need for up to 20 medical schools, a $930 value.  AMCAS estimates that 15 is the average number of schools to which students apply, so Fee Assistance provides good support for the average student.  But, applicants are applying to many more schools if they hope for a selective placement, often 30 or more.  An application costs about $100 for each school…so a marginal cost of $1000 would be a big bite for low income families, many of whom have an EFC (Expected Family Contribution) of $0 per year.  AMCAS and schools could support more applications, or free applications, for low income students or perhaps offer more free applications to applicants with higher GPA or MCAT scores that might be more competitive at selective schools.  Additionally, medical school application costs could become eligible for aid or loans from the federal government.

The next step in medical school application is secondary screening.  Typically, medical schools charge $0-200 to submit a secondary application that provide some supplementary information about the student.  A common charge would be $75.  Surprisingly, few medical schools screen primary applicants very stringently before collecting secondary applications.  Therefore, most students must pay the secondary to have their application considered in any detail.  Though many schools will waive the secondary fees for those who qualify for Fee Assistance, this could be a barrier, particularly if seeking a selective placement.  Medical schools could simply be more selective based on primary applications, or consider adding the information they feel they need from secondary applications to the standard AMCAS primary application to eliminate this step and associated charges.

Our student has now reached the most exciting and potentially most expensive stage of the process:  the interview.  Students generally get short notice of interviews, meaning they must schedule travel immediately, often expensively.  Though many students will interview and attend in-state medical schools that pose lower travel costs, some students-perhaps especially those seeking placement in very selective schools- will need to travel.  Many schools support the visit by offering that students can stay with a host student, but airfare, hotel and meals could be prohibitive for many students.  Interviews would be more convenient and much less expensive if conducted as video interviews.  This stage could probably replace the evaluative portion of the interview, though a visit for an admitted student who is choosing placement is likely to remain valuable to the applicant.

If the process continues with in-person interviews, a problem for some students  is the expected dress-suit and tie for men and women’s business suit.  Though professional appearance is important, cost could readily be reduced by asking that everyone dress in a business casual fashion (such as khakis and a polo).

Some aspects of the application and interview process could incorporate real or implicit biases based partly in applicant financial situation.  For example, many essays and applications ask for medically-relevant experiences like volunteering.  Many lower income students work while enrolled and do not have the luxury of volunteer time.  Some students lack the health insurance or personal contacts that have become more important in securing shadowing experiences to demonstrate a motivation for medicine.  Essays on applications often speak to experiences like a parent being a physician, a sibling… a preference for which could perpetuate the profession from “legacies” rather than drawing our new physicians from the general population of intellectually and emotionally qualified students.  Many lower income, first-generation families and their students are simply daunted by processes unfamiliar to them, such as college application or completion of FAFSA forms, that are central to success for lower income students.

Liz Bryant, the University of Idaho’s Premedical Advisor directed me to a more personal perspective.  Liz was immediately familiar with each of these difficulties and said that numerous students contacted her each year for advice and help.  I spoke with Megan Schlusser, a recent University of Idaho student, Pell Grant eligible, who will matriculate into our WWAMI program in summer 2019.  Megan is a first generation student, who received fee assistance.  Megan enrolled in a $900 MCAT prep course; multiple family members chipped in to make this happen.  Fee assistance enabled her to apply to the 10 medical schools she felt would offer her the best chance of acceptance.  Megan received multiple interviews, but travel was a very difficult barrier for her.  She laughed when I asked about a business suit-saying she is the first in her family to own one, and that she had to ask Liz what to buy and where to shop.  Megan felt very conscious of clothing and status on her interviews.  And, like many students, Megan worked throughout college and had limited time to shadow or volunteer.  Fortunately, she landed a job as a medical scribe in her senior year.  As our conversation evolved, Megan had clearly just accepted these difficulties and surmounted them, not considering how barriers could be lowered.  But, as we discussed alternatives, such as video interviews or business casual dress, she quickly realized that the world does not have to accommodate the wealthy at the expense of the poor.  Megan, of course, is a lucky and plucky survivor, but how many other students don’t succeed or persist?

Medical schools, prospective medical students, and the public of the United States share the goal of ensuring access to the medical profession for the best doctors.  Let’s examine each step of that pathway to ensure success depends on those qualifications rather than the financial resources of the applicants.