Time for medical schools to end legacy admissions (opinion) | Tech US News


On the fifth floor of the Tufts University Medical Education Building, chatter fills the hall as students file out of class. They are starting their first year of medical school and have just finished a class on health inequalities. Like many medical schools, Tufts has a specific population health curriculum that emphasizes the social determinants of health (SDH), which are the context in which people are born, live, and work. These circumstances have become recognizable for their extraordinary effects on the overall health of a person. Over the past several decades, curricula on the social determinants of health have been widely developed and adopted in all medical schools in the United States.

One reason SDHs are important in medical education is that patients’ social contexts influence their health more than their biomedical contexts. To prove this point, instructors often point to the dramatic increase in life expectancy in the 20th century, a result of improvements in public health, not medical advances. However, these improvements are unevenly distributed in society, so the courses at SSH also address health inequalities. Health inequalities are often viewed through the lens of education, race, income and immigration status. For example, students learn that the average black American has only 17 cents for every dollar the average white American has. Students also learn that Asian Americans have the highest life expectancy at 85.7 years, while American Indians and Alaska Natives have the lowest at 73.1 years.

To understand health disparities, instructors must help students examine the causes of such disparities. For many minority groups, this includes factors such as access to healthy food, health care, and safe neighborhoods. While some of these health inequalities occurred by chance, many were the result of discriminatory practices. The construction of freeways through communities of color, the dilution of racial groups into undesirable areas, and discriminatory legal practices affect health. Importantly, discriminatory employment practices and education policies—key parts of structural racism—work to suppress income and knowledge, which also affect health.

All this represents a distinct achievement of medical faculties. Yet they fail to reflect on structural racism in their admissions practices. Legacy admissions is not only a sign of structural racism, but also of policies that discriminate against first-generation college students and recent immigrants. Legacy admissions works by giving preference to applicants who have a family connection to the university. Formally established in the early 20th century, the legacy admissions policy was created to protect the university’s white, wealthy and Protestant student body from competition from recent European and Jewish immigrants. Today, they operate in much the same way, prioritizing the admission of white, wealthy applicants over immigrants, blacks, and individuals of lower socioeconomic status.

While the disadvantages of senior entry were well recognized in the undergraduate sphere, they were not appreciated in medical school entry. Of the nation’s top 100 universities, 75 are known to use older enrollment. While readers may believe they are only used in undergraduate admissions, medical schools are equally, if not more, guilty. Even medical schools like Johns Hopkins, which famously eliminated senior admissions in 2014, continue to ask applicants if they have relatives who attended or are employed at medical school. They state that this information is not used to determine interviews or admissions. However, concerns remain about the use of this information, who has access to it and the message it sends to applicants. Many medical schools, especially prestigious ones, are known to use older admissions when reviewing applications. While the exact algorithms for how much legacy status benefits an applicant are a closely guarded secret, one medical school has shed light on them publicly. At the University of Arizona School of Medicine, senior applicants are automatically granted an interview, a privilege offered to only 5 percent of all applicants. Furthermore, they go on to say that this is in line with many medical schools, as “most have some sort of legacy process in place.”

The reason this is such a big problem at the medical school level is that many barriers prevent applicants of color and low socioeconomic status from matriculating every year. Applying to medical school in the United States requires a bachelor’s degree, thousands of dollars in application fees, MCAT exam preparation and registration, in addition to hundreds of hours of study, application essay writing, and interviews. Additionally, inadequate connections in the medical field, insufficient knowledge of the process, and prior criminal history can easily derail any progress. In contrast, applicants who come from medical families or are otherwise high-income bear none of the financial burden of low-income applicants and often have complex knowledge of the process, application assistance, and connections to medical professionals and faculty. Finally, with medical school acceptance rates in the low individual percentiles, even if old admissions only act as a tiebreaker between two applicants—as some administrators claim—it could have a tremendous impact on admissions prospects and class composition.

Compounding the problem is the fact that physicians are 25 to 50 times more likely to have a parent who is a physician than the average population. A Stanford University study shows that medicine in Sweden is increasingly being practiced by doctors who are the descendants of doctors – results they believe can be generalized to the United States. Among doctors born in the 1980s in Sweden, almost 20 percent had parents who practiced medicine. In the US, the average medical salary is $208,000, which is almost four times the average American salary of $53,000. The result is not only a concentration of wealth, but also of medical knowledge, which has not boded well for first-generation and low-income students seeking to enter the profession, as well as for society in general.

Recently, there has been an avalanche of mass and institutional measures against the acceptance of heritage. Most importantly, after Johns Hopkins eliminated its old admissions in 2014, Amherst College joined JHU in 2021. That same year, the state of Colorado passed legislation requiring Colorado’s public universities to abandon the practice. Similar legislation is in the works in New York and Connecticut. More broadly, congressional Democrats unveiled legislation in February 2022 that would strip federal dollars from universities that use legacy admissions. Despite these measures, almost nothing has been written about the acceptance of bequests at the medical school level, and no medical school has accepted the call to abolish bequests—with Tufts University School of Medicine as a notable exception.

For decades, medical schools have been improving their curricula to teach about the social determinants of health and health disparities. It’s time for them to look at their admissions practices and assess how they contribute to structural racism and health disparities. Although this modest change will not achieve fair recognition, it is a small step in the right direction. Excise legacies of recognition.


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