Medical educators in the U.S. are learning more about the way that medical school admissions can be unfairly biased in favor of candidates with social power. Besides being unjust for applicants, this has had profound downstream effects on the quest for health equity.

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One proposal to address the issues involves factoring in applicants’ familiarity with the forces that work against them and their communities.

Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) with strategies for reconceiving meritocracy in a way that emphasizes equity—by valuing structural competency.

We must acknowledge that our systems of educating clinicians and providing care to patients are not equitable,” says the article. “Meritocracy in its current form excludes the skill sets of many.”

The article was co-written by Tomas Diaz, MD, clinical fellow in emergency medicine at University of California, San Francisco School of Medicine, Ryan Huerto, MD, MPH, fellow in the National Clinician Scholars Program at University of Michigan Medical School, and Jasmine Weiss, MD, fellow in the National Clinician Scholars Program at Yale School of Medicine.

The crux of the issue is that merit-based admissions criteria overvalue grade-point averages (GPA) and scores on standardized tests such as the Medical College Admission Test (MCAT).

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In addition, these criteria “are often presumed to be free from bias, though they favor candidates with social power,” the authors added. “Scholarly article publication, mission-trip participation and clinical shadowing are more often an index of the experience of candidates for whom social power has been part of their backgrounds.”

Meanwhile, the authors noted, candidates from backgrounds underrepresented in medicine (UIM) “are more likely to have attended high-poverty schools, less likely to have had credentialed math and science teachers, and less likely to have had programs and courses that prepare them well for undergraduate education.”

One way to level the playing field, the authors argued, is to take a more holistic view of merit.

“Admissions holism seeks to contextualize applicants’ backgrounds and life experiences—especially their experiences with stereotyping, which can cause harm and affect academic performance,” they wrote. “An equitable admissions process is one that values applicants’ ability to understand how social, cultural and political structures confer advantage to some and disadvantage to others.”

In other words, valuing structural competency isn’t just about promoting fairness in admissions. It’s also about promoting quality of care.

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“High GPAs and MCAT scores are merits, but they’re not the only merits, and they don’t reliably identify the most capable students or most facile clinical problem solvers,” the authors wrote, noting that rote memorization of content is decreasingly important due to rapid advances in technology and access to knowledge bases. “An applicant’s facility with collaboration, conscientious approach to problem solving, and grit might be traits more reliably indicative of undergraduate medical, residency or professional success than MCAT scores.”

UIM applicants might also have skills in advocacy, service and mentorship, all of which are valuable. A structurally competent learner recognizes, for example, that limited access to food can compromise a patient’s ability to control her type 2 diabetes. The physician has to tailor treatment and referrals based on such factors.

“The lived experiences of many UIM and first-generation matriculants can be sources of invaluable strength that enable their connection with diverse colleagues and patients, which is key to motivating equitable patient outcomes,” the authors wrote.

It’s not up to admissions officers alone to account for the changing landscape of health care. Faculty also may need to adjust.

“Structural competency requires learners to recognize medicine as situated among social structures (e.g., mass incarceration, racist housing policy and urban planning, and educational and socioeconomic inequity) that determine patients’ and communities’ health status and health outcomes,” the authors wrote.

The March issue of AMA Journal of Ethics further explores racial and ethnic health equity in the United States.

The AMA Accelerating Change in Medical Education consortium has developed multiple curricular resources to support education in Health Systems Science, which emphasizes structural factors in health care delivery and promotes systems thinking. For more tips on holistic selection from the consortium, view recent webinars on medical school admissions, “Focusing on Diversity: mission-aligned medical school admission and residency selection processes,” and on residency selection, “Residency application process: current challenges and potential.

Learn how the AMA Accelerating Change in Medical Education initiative works across the continuum with visionary partners to create bold innovations.

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