The Potential Impact of Scribes on Medical School Applicants and Medical Students with the New Clinical Documentation Guidelines.

The presence of scribes in various specialties, including internal medicine, is being heralded as a way to decrease clinician documentation time and burnout. Many medical school applicants become scribes to understand life as a doctor and gain clinical experience. Scribing is already perceived by some as a new key to successfully gaining entrance to medical school. One season of our admissions data showed that scribes were more likely to be admitted (OR = 1.61). Scribes may also inadvertently make it harder for medical schools to secure clinical placements for medical students. While trained scribes are highly valued by providers struggling to deal with increasing documentation burdens, supervising or training scribes also requires time that cannot be devoted to teaching. Medical documentation duties could provide valuable learning experiences for medical students. The recent ruling allowing medical students to contribute directly to clinical documentation without requiring redocumentation by supervisors gives medical schools and clinician-educators an opportunity to consider the unintended consequences of the scribe movement for medical education. Educators should consider when and how students can maximize the educational benefits of participating in patient documentation despite the templated methods commonly used in electronic health record (EHR) systems.

Impact of Masking Academic Metrics on Enrolling a Broadly Diverse and Mission-Aligned Student Body.

PROBLEM: The June 2023 U.S. Supreme Court decision overturning affirmative action required medical schools to discontinue considering race/ethnicity in admissions decisions. Medical schools must now identify different strategies if they aim to recruit and admit applicants from groups underrepresented in medicine (URiM; race/ethnicity), as enrolling broadly diverse students remains critical for serving the U.S. population. APPROACH: Washington State University Elson S. Floyd College of Medicine (established in 2015) has an admissions process that assesses academic metrics using national threshold combinations of undergraduate grade point averages (UGPAs) and Medical College Admission Test (MCAT) scores (published on school's website), and legal residency in or ties to Washington state, as prescreening criteria for secondary applications. UGPAs and MCAT scores are then masked from further consideration, allowing for decisions to be made with a focus on mission-aligned criteria, such as certain personal attributes and lived experiences and coming from specific environments (i.e., educationally or socioeconomically disadvantaged backgrounds, rural communities, military service, or a member of a federally recognized Tribe). OUTCOMES: In the last 5 admissions cycles (enrollment years 2018-2022), cohort data demonstrates that as the admissions funnel narrows and each subsequent pool is smaller than the preceding one, the representation of mission-aligned applicants increases, despite the masking of academic metrics. The most recently enrolled class (enrollment year 2022) of 80 had 14 (17.5%) URiM students, closely mirroring the state's general population. The overall yield (acceptance:matriculation) has steadily improved with the last 2 cycles to 1.68:1 and 1.65:1, indicating slightly more than 1.5 times the number of offers needed to fill the class are being made. NEXT STEPS: Next steps include further refining the process by considering more granular data on applicants' childhood community characteristics and rural background and examining how admissions data may correlate with residency and practice location and communities served.

Self-Reported Disadvantage in Medical School Admissions: A Call to Review, Revise, and Further Advance Holistic Review.

PURPOSE: This study examined how applicants interpret the self-reported disadvantaged (SRD) question in the American Medical College Application Service (AMCAS) application. METHOD: Data from 129,262 applicants who applied through AMCAS from 2017 through 2019 were used, including financial and family history, demographic characteristics, and work status and residence. Fifteen applicants from the 2020 and 2021 AMCAS cycles were interviewed about their experiences with the SRD question. RESULTS: Large effects were found for SRD applicants with fee assistance waivers ( h = 0.89), Pell grants ( h = 1.21), state or federal aid ( h = 1.10), and parents with less education ( h = 0.98) and non-SRD applicants with a large proportion of their education paid by family ( d = 1.03). Another large difference was found for reported family income distribution (73% of SRD applicants reporting family income < $50,000 vs 15% of non-SRD applicants). More SRD applicants were Black or Hispanic (26% vs 16% and 5% vs 5%), Deferred Action for Childhood Arrivals recipients (11% vs 2%), born outside the United States (32% vs 16%), and raised in a medically underserved area (60% vs 14%). There was a moderate effect for first-generation to college SRD applicants ( h = 0.61). SRD applicants had lower Medical College Admission Test scores ( d = 0.62) and overall and science grade point averages ( d = 0.50 and 0.49, respectively) but no meaningful differences in acceptance or matriculation rates. The interviews identified 5 themes: (1) unclear disadvantage definition; (2) different perceptions of disadvantage and overcoming challenges or obstacles ; (3) identification as disadvantaged or not; (4) SRD essay content; and (5) concerns about lack of transparency in how the SRD question is used in admissions. CONCLUSIONS: Revising the SRD question by including context, phrasing, and instructions for broader experience categories might be beneficial because of lack of transparency and understanding.

Enrollment Management in Undergraduate Medical School Admissions: A Complementary Framework to Holistic Review for Increasing Diversity in Medicine.

Medical schools implemented holistic review more than a decade ago, which led to more deliberate consideration and inclusion of applicants historically underrepresented in medicine. This article presents a theory of holistic enrollment management that unites holistic review with enrollment management principles. This theory contextualizes medical school admissions as a complex marketplace with multifaceted, competing forces. Applying an enrollment management framework of mission, market, means, and metrics can improve the capacity of a medical school to efficiently advance its mission over time. Medical schools employing a clear, compelling, and focused mission to direct all aspects of the medical education enterprise can more effectively attract applicants who are better prepared to enact that mission throughout their careers. Medical schools share a marketplace and collectively compete to identify, attract, admit, and matriculate the most mission-aligned student body within the pool of applicants they share. Institutions that deliberately mobilize resources within this dynamic marketplace will engage, admit, and matriculate the most suiting applicants and attract even more mission-aligned matriculants over time. Widespread adoption of this holistic framework of enrollment management may enhance the capacity of the medical education system to better capitalize on the existing diversity in the national pool of applicants, encourage more underrepresented applicants to apply in the future, admit and matriculate a more diverse national student body, and ultimately better prepare new physicians to meet the increasingly diverse health care needs of the nation.

Using holistic review to form a diverse interview pool for selection to medical school.

The holistic review in admissions framework has gained ground in medical schools. Because holistic review is unique at each institution, there is a paucity of evidence about whether it produces a more diverse interview pool than metrics-driven processes. The aim of this quantitative causal-comparative replication study was twofold: (1) to assess whether holistic review produced a more diverse interview group than one based solely on metrics and (2) to assess how the students enrolled through holistic review performed compared to national averages. Participants included 4643 medical school applicants applying for entering years 2011 through 2015. Three interview subgroups included a holistic review group (n = 1505), an academic group (n = 1505), and an overlap group (n = 1633). The sample included 44% women, 11.9% first-generation college students, and 14.9% underrepresented in medicine. Analyses found that in all categories of demographics and experiences, the holistic review group had significantly higher percentages than the academic group. One class performed lower than the national average on both United States Medical Licensing Exam Step 1 and Step 2 Clinical Knowledge; however, the other two classes performed similar to students nationally. This study supports the view that holistic review produces a more diverse interview pool than a metrics pool and is a valuable tool for increasing broad diversity.

Explicit bias among fourth-year medical students.

The aim of this study was to analyze themes related to explicit bias in patient-doctor relationships among fourth-year medical students. Class cohorts between 2013 and 2016 taking an online elective, "Self and Culture," submitted reflections about explicit bias. Thematic analysis was conducted on 283 student submissions totaling 849 entries until saturation. Themes included explicit bias toward patients with obesity, those who smoked, those from low-socioeconomic conditions, and, to a lesser extent, race/ethnicity. Themes related to the patient-doctor relationship included a negative impact on the relationship itself, trust, treatment of the patient, and patient experience. Themes related to making a positive impact included seeking positive treatment of the patient, understanding patients' circumstances rather than making assumptions, partnering with the patient, and education. Furthermore, researchers noted external versus internal attribution of the bias. Some students used neutral language to explain explicit biases, whereas fewer used internal attribution language. Results demonstrated that this type of reflection promoted personal insight, and faculty members should be trained to ensure successful crucial conversations about the impact of assumptions and biases on patient treatment, care plans, and health disparities. Finally, the curriculum should be intentional, providing experiences with marginalized populations to develop cultural humility and empathy.