Racial and ethnic minorities are disproportionately affected by the ongoing COVID-19 pandemic and the systemic racism that plagues this country. Meanwhile, the medical field grapples internally with bias and discrimination against students and physicians from these minority backgrounds. This was most recently demonstrated when a prestigious medical journal published an article1 filled with racist rhetoric that questioned whether minorities deserve to be doctors.
This recent “research article,” written by Norman Wang, MD, was published in the premier Cardiology journal, Journal of the American Heart Association (JAHA). The piece criticized the consideration of race and ethnicity in the admissions processes for medical school and medical residency. The article presents that racial and ethnic minority applicants have been “given considerable leniency when compared with other groups,” and thus their acceptance into medical school and residency results in the production of lower quality doctors. Furthermore, Wang surmises that holistic review for medical school admissions “should also not be used to promote racial and ethnic balancing, as has been suggested.”
After outrage ensued across medical social media networks, such as #medtwitter,2 the article was retracted from the journal. However, by then most of the damage was already done. This publication exposed racist beliefs held by powerful stakeholders in medicine.
The medical school admissions process is widely regarded as one of the most competitive for any academic degree. With over 50,000 applicants3 per year and a less than 5% acceptance rate for many medical school programs,4 medical school admissions committees are tasked with the challenge of deciding who will become physicians. Many medical schools, including the University of Pennsylvania Perelman School of Medicine, practice “holistic admissions.”5 This process considers an applicant’s academic and professional achievements in a variety of contexts—including age, race, ethnicity, socioeconomic status, and personal hardships—in order to ultimately evaluate an applicant’s “distance travelled” to medical school. The practice is not quota-driven, but rather acts as a multifaceted framework for selecting a diverse student body enriched by myriad life experiences. Holistic admissions acknowledges that the journeys of medical school applicants to medical training are inherently unequal.
While diversity-driven holistic admissions policies are widely encouraged and incentivized by medical school accreditation authorities, 6 they are only one small step towards addressing the overwhelming effect of structural bias against minority applicants. Despite holistic admissions, racial/ethnic minorities remain stagnantly underrepresented in medicine7. This may be due to generations of unreconciled inequitable educational resource allocation and segregation8 that leave untapped pools of applicants from diverse communities.
On the other hand, race-blind medical admissions—for which Wang advocates in his letter—completely ignores the centuries of racism and structural injustices that minority students face on the long path to medical school. Wang claims that underrepresented minorities (URMs) are given “considerable leniency” in the application process. Not only is this position false9—in fact, minority students are more likely to face harsher criticisms 10in their performance reviews—but the publication of this troubling rhetoric by JAHA also serves to further propagate the deep history of racist biases against minorities in medicine11. Events such as the murders and violence against Black people in the US, most recently seen in the recent attempted homicide of Jacob Blake—an unarmed Black man – in Wisconsin, as well as such violence perpetuated within our medical community as a medical student defaced the memorial12 of George Floyd, harshly reiterate the disproportionate racial trauma that URM students face as they enter the medical profession. These applicants show boundless resilience and grit—characteristics widely and classically valued in medical training—as they overcome barriers built by systemic racism.13 These barriers include a disparaging history of discrimination in higher education14. When considering the disparate hurdles that URM applicants face, we should agree that a system of holistic admissions is a bare-minimum responsibility of medical institutions to avoid perpetuating systemic racism and to make tangible progress towards improving diversity in medicine.
The positive effects of a diversity-aware admissions system go far beyond the inclusivity of the medical school experience. Prioritizing diversity in the physician workforce is of utmost importance for achieving health equity, especially as the ongoing COVID-19 pandemic disproportionately affects Black and Hispanic Americans15. Numerous studies have found that Black and Hispanic patients receive higher quality care with better outcomes16 when their physicians are also Black or Hispanic. Here in Philadelphia, more than 58% of Philadelphians are Black or Hispanic, while nationally, only 10.8% of physicians are Black and Hispanic17. With nine medical schools18 in Philadelphia, it is important that these schools accept a diverse workforce to train and serve the diverse Philadelphia community.
The lack of diversity in medicine, perpetuated by rhetoric revealed in Wang’s article, limits the ability of the field to rectify its racism, sexism, and other structural injustices that further perpetuate health disparities in this country. Only recently have medical institutions begun to create anti-racism policies19 that decry their histories of oppression of URM students, physicians, and—most importantly—patients. Holistic admissions policies, which seek to address these disparities, are only one step towards an equitable healthcare system. These policies must not only continue but also be elevated. Now, more than ever, minority physicians deserve to be here and are here to stay.
1. Wang Norman C. Diversity, Inclusion, and Equity: Evolution of Race and Ethnicity Considerations for the Cardiology Workforce in the United States of America From 1969 to 2019. Journal of the American Heart Association 2020;9(7):e015959.
2. #medtwitter – Twitter Search / Twitter [Internet]. Twitter. [cited 2020 Sep 3];Available from: https://twitter.com/search?q=%23medtwitter&prefetchtimestamp=1599158007406, https://twitter.com/search?q=%23medtwitter
3. AAMC. Chart 1: Applicants, First-Time Applicants, and Repeat Applicants to U.S. Medical Schools, 1980-1981 through 2018-2019 [Internet]. 2018;Available from: https://www.aamc.org/system/files/reports/1/factsdatachart1.pdf
4. The Best Medical Schools for Acceptance Rate, Ranked [Internet]. [cited 2020 Sep 3];Available from: https://www.usnews.com/best-graduate-schools/top-medical-schools/hardest-to-get-into-rankings
5. Holistic Review [Internet]. AAMC. [cited 2020 Sep 3];Available from: https://www.aamc.org/services/member-capacity-building/holistic-review
6. LCME. Liaison Committee on Medical Education (LCME) Standards on Diversity. 2008;
7. Lett LA, Murdock HM, Orji WU, Aysola J, Sebro R. Trends in Racial/Ethnic Representation Among US Medical Students. JAMA Netw Open 2019;2(9):e1910490–e1910490.
8. Gambardello JA. Philadelphia schools still segregated as suburban districts integrate, analysis finds [Internet]. https://www.inquirer.com. [cited 2020 Sep 4];Available from: https://www.inquirer.com/education/philadelphia-schools-race-integration-suburbs-washington-post-20190912.html
9. Analysis challenges idea that black medical school applicants are “stealing” spots from white applicants | Inside Higher Ed [Internet]. [cited 2020 Sep 4];Available from: https://www.insidehighered.com/admissions/article/2018/01/15/analysis-challenges-idea-black-medical-school-applicants-are-stealing
10. Differences in Narrative Language in Evaluations of Medical Students by Gender and Under-represented Minority Status – PubMed [Internet]. [cited 2020 Sep 3];Available from: https://pubmed-ncbi-nlm-nih-gov.proxy.library.upenn.edu/30993609/
11. Bullock SC, Houston E. Perceptions of Racism by Black Medical Students Attending White Medical Schools. J Natl Med Assoc 1987;79(6):601–8.
12. Man caught defacing George Floyd memorial once a UMN medical student [Internet]. The Minnesota Daily. [cited 2020 Sep 3];Available from: https://www.mndaily.com/article/2020/08/man-caught-defacing-george-floyd-memorial-once-a-umn-medical-student
13. Untold Barriers for Black Students in Higher Education – Southern Education Foundation [Internet]. [cited 2020 Sep 3];Available from: https://www.southerneducation.org/publications/untoldbarriers/
14. Nora A, Cabrera AF. The Role of Perceptions of Prejudice and Discrimination on the Adjustment of Minority Students to College. The Journal of Higher Education 1996;67(2):119–48.
15. CDC. Communities, Schools, Workplaces, & Events [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Sep 4];Available from: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
16. Alsan M, Garrick O, Graziani GC. Does Diversity Matter for Health? Experimental Evidence from Oakland [Internet]. National Bureau of Economic Research; 2018 [cited 2020 Sep 4]. Available from: http://www.nber.org/papers/w24787
17. Figure 18. Percentage of all active physicians by race/ethnicity, 2018 [Internet]. AAMC. [cited 2020 Sep 4];Available from: https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018
18. Medical Schools in the Philadelphia Region [Internet]. Philadelphia Business Journal. [cited 2020 Sep 3];Available from: https://www.bizjournals.com/philadelphia/subscriber-only/2015/05/15/medical-schools.html
19. Our Statement on Anti-Racism [Internet]. [cited 2020 Sep 4];Available from: https://health.ucdavis.edu/phs/news/statement-on-anti-racism.html
Editors’ Note on 9/8/20: Wording adjusted in fourth paragraph to emphasize that many individual medical school programs, as opposed to medical schools as an aggregate during each application cycle, have an acceptance rate less than 5%.
Cheyenne Williams, Olivia Familusi, and Michael Perez are fourth year medical students at the Perelman School of Medicine at the University of Pennsylvania.
