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US Supreme Court and Holistic Admissions

By: Billy Thomas, MD, MPH

I recently participated in the first in a series of meetings in which 174 students will be selected to fill the next freshman class of the UAMS College of Medicine. The agenda and content were the same as usual, but given the current degree of national social unrest, I felt an urgency to reflect on social justice and equity in this critical period in our nation’s history.

A recent article in The Chronicle of Higher Education highlighted recent protests by minority students at colleges and universities across the country. The students as well as minority faculty called for greater inclusion and transparency and better support services. These protests have drawn attention to ever widening racial disparities in higher education. In particular, minorities (African Americans and Hispanics/Latinos) make up a small proportion of professors, presidents, and the student bodies of selective colleges (1).

Recent pressures on our educational system to be more diverse, inclusive, transparent, fair, and equitable are not about anything new. The protests were simply an expression of dissatisfaction with the slow rate of change, precipitated by the current state of social unrest. The reasons are complex, stemming from multiple factors, most proximal being the recent shootings of black males by police.

Nationally, tensions are running high on matters to do with identified groups (based on race, religion, sexual orientation and socio-economic class) who are perceived as “other” and what constitutes fair treatment for all. Consider the current xenophobic views on immigration, how to deal with terroristic threats, either external or domestic, and ongoing legal battles surrounding same-sex marriage and domestic partner health care benefits. And once again, the US Supreme Court is deliberating on the use of race by institutions of higher learning as one of many factors in the admission process.

Academic health centers (AHCs) must respond to current tensions with sensitivity to their mission and a commitment to fairness and equity. AHCs do not exist in a vacuum. We are microcosms of society. What ails society also exists within our institutions. The anger and mistrust currently bubbling to the surface in minority communities is about more than a seemingly new increase in racially motivated acts of aggression by law enforcement. Many of the inciting issues are longstanding and static.

Health care in this country has committed some of the most egregious racially motivated acts. The Tuskegee clinical trials, in which known therapy for syphilis was withheld from African-American male patients, and experiments during World War II, in which minority soldiers were involuntarily exposed to mustard gas, are but two instances of blatant discrimination, inhumanity, and the immoral and unethical delivery of health care (2, 3).The work to address wrongs and build trust is ongoing.

The transgressions against marginalized and minority populations are not all-of-a-sudden events or true only of law enforcement or health care. Thus, mistrust is pervasive.

In focusing on health care and the need for a diverse health care workforce in the delivery of equitable quality care, we need to pose the question: “Have we progressed?”

The Bakke decision allowing race-conscious admissions was handed down 38 years ago in 1978. It was a huge step for affirmative action and actually remained at the forefront of the postsecondary admissions process until 2003, when Grutter v. Bollinger again supported race-conscious admissions and the use of race as one of multiple factors in the selection process as long as no specific number, weight or percentage is attached to it and as long as it satisfied the requirements of “strict scrutiny.” (4) This ruling remained in place for several years until Fisher v. the University of Texas at Austin made a very similar challenge. Again race-conscious admissions was upheld in a lower court, but the US Supreme Court ruled that the lower court had not adequately applied strict scrutiny, meaning that the lower court had not performed due diligence in its determination that race-neutral or other policies established by University of Texas were not as effective. The case went back to the lower court, where essentially there were no additions to the original argument. It is now again being deliberated by the US Supreme Court.

Given recent remarks by Chief Justice Roberts and the late Justice Antonin Scalia* during oral arguments in December, along with the fact that the makeup of the Supreme Court has not changed since its last ruling, I’m not optimistic about the eventual ruling on the case, which will be later this year.

Chief Justice Roberts posed two questions: “What unique perspective does a minority student bring to a physics class?” and, “I’m just wondering what the benefits of diversity are in that situation?” (5) Justice Scalia stated, “I’m just not impressed by the fact that the University of Texas may have fewer [black students if the admissions policy changes]. Maybe it ought to have fewer. And maybe, when you take more, the number of blacks, really competent blacks, admitted to lesser schools, turns out to be less,” he added. “I don’t think it stands to reason that it’s a good thing for the University of Texas to admit as many blacks as possible.” (6) It is as if both justices have lost sight of the original intent of the Civil Rights Act, desegregation/integration, affirmative action and the well documented benefits of a diverse student body.

This lack of insight and the intimation of a willingness to regress to a separate but equal society by two Supreme Court justices is very concerning. We could just shrug our shoulders and say, “Well, they are only human, and we all make poor decisions,” but somehow I feel being human carries with it a higher calling or an innate sense that allows us to see, feel and maybe understand the lives, perspectives and struggles of others. Can a society that is separate but equal be sustained? Probably not. This is an extremely important case, and my hope is it will be sent back to the lower court, requiring the University of Texas to provide additional information to fulfill the requirements of strict scrutiny. Doing so will demonstrate that student body diversity is a compelling interest to the University of Texas and the state.

Given this backdrop, the current cycle of admission committee meetings is a unique opportunity for UAMS to demonstrate its values as an AHC. Relevant are two seminal publications, the Institute of Medicine report, Unequal Treatment and Missing Persons: Minorities in the Health Professions. (7,8).  Both reports expose the racial and ethnic health and health care disparities that exist as a result of barriers within the health care system due to biases, discrimination, racism and stereotypes. The two reports call for a more inclusive, equitable health care system and serve as a template for how to get there. A workforce that is more diverse and culturally competent is a key aspect of the change that is needed.

It is relevant that the US population is undergoing dramatic demographic shifts. By 2060, as a proportion of the total population, the non-Hispanic white population under age 18 is predicted to drop from 53% (2012 estimate) to 33%, and the Hispanic/Latino population will increase from 24% to 38%. There will be no real majority (9). As these shifts take place we must ask ourselves, “Who is the community to whom we are accountable, and what are their needs with respect to the recruitment, admission and training of health care providers?” (10) If we truly believe that everyone in the community is entitled to the same quality of care, then we must be strategic in our responses to an ever-changing population. If we agree with Dr. Sullivan, when he said health care must be provided by a well-trained, qualified, and culturally competent health professions workforce that mirrors the diversity of the population it serves, then this must be central to the overall mission and admissions process at Arkansas’ academic health center.

As an AHC goes through the admissions process, the overall objective should be the construction of a health care workforce that will provide equitable and quality care to a diverse population. It has been well documented that a diverse, culturally competent health care workforce results in multiple positive outcomes including improved patient access, higher quality of care, increased patient involvement in the care plan, increased adherence, and more positive patient perceptions of care–all leading to reduced health disparities and improved population health, providing valid reasons for pursuing and promoting diversity in higher education (11).

The use of the holistic admission process provides a framework with which an AHC is able to identify, recruit and retain students that in many cases share life experience with the increasingly diverse community they serve. As stated by Kirsch and Mahon, we should look for physicians that are strong in the natural sciences, have a good bedside manner, and communicate well. The goals of holistic review are to assess each applicant’s academic readiness, their interpersonal and intrapersonal competencies, and to encourage diversity in medical education (10).

Key to the success of the holistic admission process is diversity and the achievement of a “critical mass.” Not a predetermined number or quota but a level of structural diversity at which there is a measureable reduction in the reported incidence of discrimination, biases, stereotyping, and exclusion and an increased sense of belonging (12). Diversity has been shown to directly increase student academic performance, student retention, student community engagement, student cooperation, team work and openness to different ideas and perspectives. All leading to an institutional environment that is inviting and nurturing and an educational process in which all students, faculty and staff benefit (13).

As we await a decision by the US Supreme Court, the need to clearly define the components, intent and utilization of the holistic admission process must take center stage at all AHCs. As has been demonstrated at multiple institutes that have drifted away from the use of a race-conscious admission policy, many have experienced a gradual decline in the number of minority applicants and matriculates (14).

This we must avoid. Given the low numbers and very static nature of our national applicant pool, the utilization of a true holistic admissions process may be one way to slow the trend and perhaps increase the number of underrepresented minorities in health care.

*Since the original writing of this commentary Justice Antonin Scalia suddenly passed away in his sleep of natural causes.  This leaves a very large void in a Supreme Court that is now evenly split. This has created a great deal of political and social anxiety and speculation about the timing and who will replace Justice Scalia. Politically, congress favors delaying the appointment and allowing the newly elected President to make the appointment. While President Obama pledges to move forward with the appointment as it is outlined in the US Constitution.  In a split court the upcoming appointment will play a pivotal role in the overall outcome of several Supreme Court rulings including immigration and race-conscious admissions policies (holistic admissions). As we await the decision the need to clearly define the components, intent and use of the holistic admission process becomes even more important. 

  1. Peter Schmidt. New Study Fuels Debate over ‘Mismatch’ Theory in Race-Conscious Admissions. Chronicle of Higher Education. 17, 2015.
  2. S. Public Health Service Syphilis Study at Tuskegee. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. Dec. 14, 2015.
  3. Joe Tacopino. African-American Soldiers Used for World War II Mustard-gas Experiments. New York Post. June 23, 2015.
  4. Curfman G.D., Morrissey S., and Drazen J.M. Affirmative Action in the Balance. New England Journal of Medicine, 368:1;J 3, 2013.
  5. The ‘Benefits’ of Black Physics Students. New York Times. Dec. 17, 2015.
  6. We are Excelling in Every Field: Black Students Rebuff Justice Scalia. Alijazeera American. Dec. 18, 2015.
  7. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care; Smedley, B.D., Stith, A.Y., Nelson, A.R., Eds. National Academic Press: Washington, DC, USA, 2002.
  8. Missing Persons: Minorities in the Health Professions. A Report of the Sullivan Commission on Diversity and the Health Care Workforce. Sullivan Commission on Diversity in the Health Workforce: Washington, DC, USA, 2004.
  9. Frey W.H., Brookings Institution Analysis. U.S. Census Bureau Population Projections. Released 12/12/2012
  10. Mahon K.E., Henderson M.K, and Kirch G.D. Selecting Tomorrow’s Physicians: The Key to the Future Health Care Workforce. Academic Medicine, 88:12/Dec. 2013.
  11. Cooper, L.A.; Roter, D.L. Patient-Provider Communication: The Effect of Race and Ethnicity on Processes and Outcomes of Healthcare. In Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care; National Academies Press: Washington, DC, USA, 2002.
  12. Hurtado, S., & Ruiz Alvarado, A. (2015) Discrimination and bias, underrepresented, and sense of belonging on campus. Los Angeles, CA: Higher Education Research Institute.
  13. Holistic Admissions in the Health Professions. FINDINGS FROM A NATIONAL SURVEY. Urban Universities for Health. September 2014.
  14. Richard D. Kahlenberg, a senior fellow at the Century Foundation, is editor of “The Future of Affirmative Action: New Paths to Higher Education Diversity after Fisher v. University of Texas.” The Century Foundation.