A

R T I C L E

An Admission Model for Medical Schools

Janine C. Edwards, PhD, Carol L. Elam, EdD, and Norma E. Wagoner, PhD
ABSTRACT
Complex societal issues affect medical education and thus
require new approaches from medical school admission
officers. One of these issuesthe recognition that the
attributes of good doctors include character qualities such
as compassion, altruism, respect, and integrityhas resulted in the recent focus on the greater use of qualitative
variables, such as those just stated, for selected candidates.
In addition, more emphasis is now being placed on teaching and licensure testing of the attributes of the profession
during the four-year curriculum. The second and more
contentious issue concerns the system used to admit white
and minority applicants. Emphasizing character qualities
of physicians in the admission criteria and selection process involves a paradigm shift that could serve to resolve
both issues.

edical school admission is a perennial topic of

interest, not only to the administrators and faculty of the 125 allopathic medical schools in
the United States but also to the thousands of
applicants, their families, and the undergraduate faculty who
have taught those applicants and are their advocates. Any
number of issues in admission surface from time to time that
need attention. Some are of a long-standing nature and serve
as grist for the admission committee mills. However, others
emerge and gain national attention and require considerably
more effort to find some measure of resolution.
In the latter instance, a recent focus on the greater use of

Dr. Edwards is associate professor and vice chair for academic affairs, Department of Family Medicine, Texas A & M University College of Medicine,
College Station, Texas; Dr. Elam is assistant deal of admissions, University
of Kentucky College of Medicine, Lexington, Kentucky; and Dr Wagoner
is dean of students, University of Chicago Pritzker School of Medicine, Chicago Illinois.
Correspondence and requests for reprints should be addressed to Dr. Edwards,
Department of Family and Community Medicine, College of Medicine, Texas
A & M University Health Science Center, 154 Reynolds Medical Building,
College Station, TX 77842-1114; telephone: (979) 845-7829; fax: (979)
862-1372; e-mail: jcedward@medicine.tamu.edu.

To make this or any paradigm shift in admission policy,

medical schools must think about all the elements of admission and their interrelationships. A model of medical
school admission is proposed that can provide understanding of the admission system and serve as a heuristic
guide. This model consists of (1) the applicant pool; (2)
criteria for selection; (3) the admission committee; (4)
selection processes and policies; and (5) outcomes. Each
of these dimensions and the interrelationships among the
dimensions are described. Finally, a hypothetical example
is provided in which the model is used to help a medical
school change its admission process to accommodate a
new emphasis in the schools mission.
Acad. Med. 2001;76:12071212.

qualitative variables for selecting candidatessuch as compassion, altruism, respect, and integrityserves the important goal of emphasizing character qualities that ensure
greater professionalism among future physicians. The second
and more contentious issue has been the system used to admit white and minority applicants, decried by some as a twotier admission system. Nearly everyone recognizes the educational and societal benefits of a racially and ethnically
diverse student body, and in that context, minority student
admission has become a compelling question that has
reached the highest courts in several states. Using race as a
factor in admission, a practice that has been in place since
the famous Bakke case,1 has come under attack in recent
years. Many believe it is a matter of time before this issue
will resurface in the U.S. Supreme Court to be debated
again.
In this article, we first explore the factors that have led
to greater emphasis on qualitative variables in selecting medical students and assessing the conduct of physicians. We
then outline an admission model that can be useful in making this or other shifts in emphasis in a schools admission
process, and that also can help deal with the difficult issue
of diversity in admissions. Last, we give an extended hypo-

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ADMISSION MODEL,

thetical example of the use of the model to implement a

specific change in emphasis from primary care to research at
one medical school.
GREATER USE

OF

QUALITATIVE VARIABLES

What factors have led the medical education community to

call for greater use of qualitative variables in selecting and
assessing the conduct of physicians? In the recent book Time
to Heal,2 Ludmerer spoke about the need for academic health
centers to restore the social contract. He stated that in the
1990s a second revolutionary period in American medical
education began. Managed care, with its emphasis on seeing
patients quickly, was making it increasingly difficult for doctors to practice in concordance with many traditional professional teachings and values.2, p. 387 Further, the inability
to use clinical revenues to cross-subsidize education, research, and charity care was destroying the learning environment. As institutions have become more financially
burdened, dilemmas faced by American medicine in reestablishing long-held precepts about the importance of the patient, and of educating future physicians to uphold important
and long-standing professional values, have begged for solutions. Dr. Ludmerer noted that over time society tends to
reward groups that aspire to improving the human condition, and that American society in the twenty-first century
is likely to reward the medical profession if it succeeds at
placing the interests of patients and the public first.2, p. 397
Interest in humanistic factors and other attributes of the
profession have not always been given high priority in the
selection of medical school candidates. This is not out of
lack of desire on the part of committees. Difficulties in agreeing upon important variables and how to obtain valid and
reliable measures by which to support the use of these variables have proven much more challenging. An important
step was taken in 1996, when the Association of American
Medical Colleges (AAMC) established the Medical School
Objectives Project (MSOP).3 The goal of the first phase of
this project was to develop a consensus within the medical
education community on the attributes that medical students should possess at the time of graduation. Attributes
that included altruism, integrity, respect, empathy, and compassion were identified. In addition, the Liaison Committee
on Medical Education (LCME), the accrediting body for
U.S. medical schools, is now reviewing the programmatic
efforts by medical schools to teach professionalism and to
demonstrate, through appropriate assessments, the efficacy of
those efforts.
Another sign of the new emphasis on humanistic factors
occurred when the National Board of Medical Examiners
(NBME) announced its intention to require that examinees
seeking licensure to practice in this country pass an examination that assesses professionalism, communication, and

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CONTINUED

interpersonal skills. In a similar vein, the Accreditation

Council on Graduate Medical Education (ACGME), in conjunction with the American Board of Medical Specialties
(ABMS), recently finalized the definitions describing their
specialty-specific professional competencies.4 Among the six
defined competencies are two relating to important qualitative aspects that have relevance for the admission process.
The first, communication and interpersonal skills, states that
residents must demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other
members of the health care team. The second is professionalism, where residents must demonstrate behaviors that reflect a commitment to ethical practice, an understanding
and sensitivity to diversity, and a responsible attitude toward
patients and the profession.
The policy of the American Board of Internal Medicine
(ABIM)5 states that internal medicine physicians applying
for certification must be evaluated for demonstrated humanistic qualities that include integrity, respect, and compassion
in their relationships with patients and their families in order to become board certified. The ABIM has recognized the
importance of high moral and ethical standards, such as outstanding professional behavior, and has sought to lead by
example in its certification requirements. Other specialties
are now beginning to follow suit through revision of their
own processes and requirements.
Based on the changes in direction of the groups mentioned above, there is increasing pressure for medical schools
to ensure that entering students bring the requisite attributes
to succeed in the additional humanistic areas that will be
required of them for licensure and certification. It will not
be long before medical schools themselves are required by
some organization or accrediting entity to demonstrate how
they are making judgments about whether candidates entering their medical schools possess these attributes. Moving
toward the inclusion of greater use of qualitative variables
will require a paradigm shift in how admission committees
go about their business.
There are recognized barriers to making this paradigm
shift away from the highly focused quantitative assessment
that now drives the selection process. In June 1998, the Arnold P. Gold Foundation held an invitational conference
entitled Challenging the Barriers to Sustaining Humanism
in Medicine: Selecting Humanistic Candidates for Medical
School,6 in which barriers to selecting such candidates were
identified and a range of possible solutions promulgated.
Publication of rankings of U.S. medical schools based on
quantitative variables as the primary source data for the
rankings is an obstacle. Detailed information of that type
about medical schools can be found in the Association of
American Medical Colleges medical school admission requirement handbook (MSAR).7 For example, this publica-

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ADMISSION MODEL,

tion enables schools to provide relevant data to applicants,

including the mean grade-point average (GPA) of each
schools applicants and their Medical College Admission
Test (MCAT) scores. Rarely does the schools information
include documentation about the important personal attributes and character qualities that are relevant to their selection process. Although it is true that producing details of
cognitive-based scores for candidates helps the prospective
candidate focus on his or her chances for obtaining entrance
at a particular school, such publications also give the message that these variables are what count most in the selection process.
One important reason that expanding schools admission
focus to include humanistic qualities is difficult is that the
admission process is very expensive in terms of time, money,
and effort for all involved. To ask overburdened applicants
to do more, or in any way lengthen the process through more
extensive screening or by increasing the number of interviews granted, is a difficult concept to sell to faculty. Faculty
members are not rewarded through any tangible institutional
means for the time they invest in the admission process.
Another reason that introducing a humanistic focus is not
easy is that considerable faculty time and effort are sometimes spent on issues of diversity; the solutions reached are
sometimes not ideal. For example, when attempting to meet
an institutional goal of having a diverse class, coming to
grips with the fear of lawsuits often causes committees to
play it safe by resorting to numbers. In addition, helping
interviewers understand issues of diversity, including ones
own biases, is a significant hurdle. Yet, as is explained in the
next section, the introduction of a humanistic focus can help
admission committees achieve greater diversity in the
schools student body.
Solutions to some of the challenging problems suggested
at the barriers conference will require institutional buy-in
as to the importance in making this paradigm shift possible.
The medical school representatives at the conference felt
strongly that they needed to enlist the help of many groups
involved in this process. One such group that was identified
was the health-professions advisors. Enlisting their assistance
in identifying important humanistic traits in candidates
could serve as a very important first step. The medical
schools would need to hold workshops for advisors and establish collaborative arrangements to determine what important qualitative information they believe would be possible to gather and to include in letters of evaluation.
At the local level, each school would need to identify and
define criteria important for selecting humanistic candidates
and promulgate this information throughout the institution.
The admission committee would need to develop guidelines
for assessing criteria such as altruism, service orientation, respect for others, empathy, judgment, and honesty. Interviewers in the medical school would need to be trained, and an

CONTINUED

Figure 1. A model of admission to medical school that embodies generally

accepted dimensions of admission and their relationships. The model can
assist in thinking through admission issues, since it systemizes those factors essential for admission.

institutional measurement instrument would need to be constructed to ascertain how well the admission process succeeded in selecting candidates with the desired attributes.
Each institution would also need to strategize about how to
market humanism as a value within and outside the institution, through publicity, awards, and the admission materials themselves. Alumni support for the importance of humanism would need to become an institutional goal.
Ultimately, institutions would need to connect their efforts
to the requirements of the LCME, the NBME examination,
the ACGME, and the certification and recertification processes of the various specialities.
A USEFUL ADMISSION MODEL
Gaining momentum for this paradigm shift remains one of
the great challenges faced by all medical schools. Convincing faculty members that qualitative variables should have a
more equal weight in selecting candidates often leads to accusations of making the process too soft, too diffuse, and too
difficult to defend. However, we believe the time is right to
take the steps toward change. To make a paradigm shift in
the admission process, we must think about all the elements
of that process and their interrelationships. An admission
model can foster greater understanding of the admission process and can serve as a heuristic guide.8 Use of a graphic or
pictorial model, such as that in Figure 1, is helpful in imaging the components of the model and suggesting how
those components, or dimensions, relate to each other.9 Referring to the dimensions of the admission model can assist
in thinking through admission issues, thus making the whole

ACADEMIC MEDICINE, VOL. 76, NO. 12 / DECEMBER 2001

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ADMISSION MODEL,

planning process more systematic, since the model synthesizes those factors essential for admission.
The model for admission embodies dimensions of admission that are generally recognized and accepted: (1) the applicant pool; (2) criteria for selection; (3) the admission
committee; (4) selection processes and policies; and (5) outcomeseach of these is briefly discussed in the following
paragraphs. Criteria for admission serve as a major focal
point among the dimensions. Expanding such criteria has
already helped establish the new humanistic paradigm in the
admission process in the difficult area of ensuring diversity
among medical students. In many instances, in states where
antiaffirmative-action issues have been particularly prominent, the medical schools have already taken the lead to
expand their admission criteria to include greater qualitative
aspects to ensure that they can continue to attract diversified
classes.10 We feel strongly that the contribution of a model
such as the one proposed here is not to create new admission
criteria or other content, such as a research study would
create, but to synthesize elements to provide a framework
for thinking.

CONTINUED

ria, undergraduate science GPA and MCAT scores hold sway

as the most important. These quantitative criteria have
yielded some evidence of validity and reliability,12 and they
are efficient to process. In general, it is fair to say that underrepresented minority applicants as a group do not have
quantitative qualifications equal to those of majority applicants; yet there is evidence that most underrepresented minority students do succeed in medical school and in obtaining residency positions.13 The differential achievement of
underrepresented minority applicants on the MCAT has
been documented and studied.14 However, given the current
well-organized and well-financed attack on affirmative action
programs in higher education and professional education,
medical school administrators must document the objectivity
of their selection processes. As a result, they are reluctant
to use subjective information related to personal characteristics, since these show little evidence of validity and reliability. This difficulty does not decrease the need for a
greater focus on qualitative variables, for the reasons discussed earlier in this article.
The Admission Committee

The Applicant Pool

This dimension of the model can be thought of by group
and also by individuals. That is, the applicant pool includes
the number of applicants each year as well as all the variables
that define each individual applicant. Everyone involved in
the admission process scrambles each year to keep abreast of
the latest statistics of this sort. The Association of American
Medical Colleges regularly publishes statistics related to
number of applicants, MCAT scores, and demographic
trends of applicants throughout the cycle of admission. Each
medical school compiles and disseminates its set of descriptive statistics related to its applicant pool. At annual national, state, and regional medical education meetings these
statistics are presented, compared, and discussed. Studies of
this dimension can help determine the extent of the applicant pool fluctuations over time, which could be useful in
interpreting changes in the applicant pool and perhaps in
predicting future applicant pool size.11
Variability among individual applicants is another aspect
of this dimension. The character traits of individual applicants are of special concern in our society because medical
educators recognize that fostering attributes of the profession
must become central to medical education. Therefore, there
are important relationships between the applicant dimension
and the dimension of criteria for admission, discussed next.
Criteria for Admission
Academic, or cognitive, criteria are the mainstay of most
medical schools selection processes. Of the cognitive crite-

1210

The composition of the admission committee can account,

in large part, for admission policies in each medical school.
In many schools, the admission committee is directly responsible for defining the criteria for admission in concert
with the institutional mission. Recommending faculty members, students, community members, and others to serve on
the committee is an important task each year for the chief
admission officer. Negotiating the appointments for the committee with the dean and department chairs requires experience and skill to achieve a committee that operates effectively. The methods by which the committee assimilates new
committee members and inculcates them with the committees values is critical. Studies of decision-making styles of
the committee and voting patterns among members can shed
light on these relationships.15 Determining ways to recognize
and reward faculty members for service on the committee is
also a challenge.
Selection Processes
Each medical school designs its own selection process, although many aspect of selection processes are similar among
the various schools. Many medical schools continue timehonored traditions in their selection processes year after year.
Screening initial applications, deciding which applicants
should receive secondary applications, reading letters of recommendation and complete applications, weighting various
criteria, deciding which applicants to interview, decision
making, extending offers of acceptance, and attending to the
national traffic rules regarding due dates are all aspects of

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ADMISSION MODEL,

the selection process. These aspects interrelate with one another and with the other dimensions of the model. The introduction of AMCAS 2002, the electronic application system, may change screening procedures and have an impact
on decisions.16
The interplay between the criteria and selection processes
is particularly important. For example, if the criteria include
attributes of the profession such as compassion and respect
for persons, do the selection processes include appropriate
methods of evaluating those attributes, such as interviewing
and evaluation of compassion and respect in the interview?
If there is a tradition to value legacy in the medical school,
is that value explicitly acknowledged, or are decisions to
admit applicants from alumni families made behind the
scenes? Is value added by having committee members deliberate on the overall competitiveness of each candidate for
admission, or should weighting formulas be used to determine the admission decision? If both academic criteria and
attributes are included in decision formulas, do the weighting formulas give equal weight, or do these formulas favor
one type of criterion over the other type? These examples
illustrate the complex interplay between criteria and selection processes.
Outcomes
What are the outcomes of admission to medical school?
Which admission criteria are the best predictors of academic
performance in medical school? Which admission criteria are
most helpful in predicting the academic success of underrepresented minority students in medical school? Which admission criteria are the best predictors of faculty or peer ratings of professionalism and other qualitative behaviors?
Short-term outcomes are the matriculating students progress
through the medical school curriculum marked by course
grades and licensure exam scores, selection of a specialty, and
progress into graduate medical education. The ultimate outcome may be the skillfulness and humaneness of care for
individual patients. In addition, population care is very
much a current issue and may be perceived as a more important outcome in the future.
APPLYING THE MODEL
Consider this example: Assume that your medical school is
an institution established by a state legislature to produce
more primary care doctors than the traditional specialty-oriented medical schools. Your admission criteria and process
have been tailored to fit that mission of your medical school
for the past 20 years. Applicants have been recruited and
selected on the basis of their interest in practicing primary
care medicine.
Now your dean wants to step away from that primary care

CONTINUED

mission and build the research enterprise in the medical

school. He or she has conducted a strategic planning process
in which research emerged as a new priority for the school.
The dean has advised you, the director of admission, that
the new institutional mission is to develop research and that
this mission must become a priority in admitting applicants.
How do you proceed? Using the model of admission discussed here, you can begin thinking systematically about
each dimension in order to change your admission processs
orientation. The applicant pool is an obvious starting point.
In your current applicant pool, about how many candidates
are interested in research? Can you expand that number,
through both in-state and out-of-state recruitment? Do you
need to have the policy about the number of in-state students in the class changed? What recruiting programs are in
place or need to be developed to increase potential students
interest in research? What marketing materials need to be
prepared for your applicants about research opportunities?
What information does your Web site contain about research at your institution? How can you revise your Web
site? How would you go about enlisting the aid of the premed advisors to interest more applicants in research?
The criteria for admission are another dimension of the
admission model to consider in relation to research. How
will the school criteria have to be changed to admit more
students who want to combine research with clinical patient
care? What courses should undergraduates take to prepare
themselves to participate in research in a medical center?
Would you anticipate that the minimum acceptable science
GPA and MCAT scores would be different for students interested in research compared with the scores of those interested in primary care? What personal qualities are important for future biomedical researchers? Who can provide
information to help you define those necessary personal
qualities? How would you gather information about those
qualities during the application process? Should you ask for
different information from the premedical advisors in the
letters of recommendation that they forward to the medical
school? Obviously, there will have to be a criterion about
research experience. What are the nature and the extent of
prior research experiences that one should expect from candidates for admission? Is an MDPhD program necessary?
How are the selection criteria for that program interrelated
with the selection criteria for the MD program? It seems
likely that all of these factors will require policy changes.
Policy changes lead to another dimension of the model
the admission committee. How should this new research
priority be presented to the committee? Is the dean mandating this change in priority, or does he or she want the
committee to develop a consensus to make this change? How
many of the committee members will be receptive to this
change? If the majority are not receptive, how can they be
persuaded to change? Will a new committee have to be con-

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ADMISSION MODEL,

stituted? How long will it take for the committee to change

the policies? How will the new policies be implemented?
How can the committee be educated about the opportunities
for research within the medical school so that they can discuss this issue intelligently with the applicants?
What changes need to be made in the selection process?
On the secondary application, should new questions be
asked about research interests? How can interviewers be
trained to explore an applicants qualifications and level of
interest in research? Will the committee decision process
have to be changed? Discussion of that question may depend
upon how many of the committee members are receptive to
the new research priority. If the majority will accept the new
priority, then perhaps the decision process can remain the
same. But if a critical mass of the committee members are
skeptical or negative, the decision process may have to be
changed so that they will not block implementation of the
research priority.
The final dimension to be considered comprises the outcomes. Would the school expect all medical students to perform research? How would the school evaluate their performances? Would the curriculum have to be changed to
allow more flexibility in the third and fourth years for students to participate in research? Will licensure exam scores
increase or decrease? Would it be expected that the school
will graduate more clinical researchers and fewer practitioners? What admission criteria will best predict the outcome
of producing clinical investigators? How will the advising
program have to change to support that new outcome? Will
a greater percentage of the students enter academic medicine?
This is a scenario that, in a variety of forms, is being
played out in a number of medical schools established 20
years ago. During the past ten years, many medical school
admission committees have had to grapple with the opposite
scenariothat is, they have had to change their priorities
to produce more primary care doctors. Thinking about admission in the dimensions of the proposed model can make
planning more systematic. The model synthesizes those factors essential for admission.
CONCLUSION
In this article, we have tried to show that formulating a
model for medical school admission can be helpful, especially given the societal forces for change that can affect
admission policies. Emphasis is being placed on teaching and
licensure testing of the attributes of the professionby
greater use of qualitative variablesduring the four-year
curriculum. It is logical, therefore, to include those attributes
in the admission criteria and selection processes. Furthermore, as indicated earlier, the selection of underrepresented
minority applicants who can succeed in medical school may

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CONTINUED

be facilitated by the use of criteria concerning attributes of

the profession in addition to academic criteria. A model of
medical school admission, such as the one we have proposed,
can represent the complexities of admission and help decision makers organize and interpret facts, generalize without
attempting to standardize, and stimulate hypotheses for further study.
A major benefit of building a model is that it can stimulate and guide future research. A thorough review of research
studies about admission to medical school during the past
decade is needed. The last review of literature about admission was published in a thematic issue of Academic Medicine
in 1990.17 The model can provide a framework for reviewing
existing studies and also point out which dimensions require
further study. Through this and other uses of the model, the
forces that challenge us are more likely to lead to creative
and productive thinking for the future.
REFERENCES
1. Regents of the University of California v. Bakke, 438 U.S. 265, 1978.
2. Ludmerer KM. Time to Heal: American Medical Education from the
Turn of the Century to the Era of Managed Care. New York: Oxford
University Press, 1999.
3. The Medical School Objectives Writing Group. Learning objectives for
medical student educationguidelines for medical schools: Report I of
the Medical School Objectives Project. Acad Med. 1999;74:138.
4. Leach DC. Evaluation of competency: an ACGME perspective. Am J
Phys Med Rehabil. 2000; 79:4879.
5. Blank LL. Humanistic Qualities: The Art of Medicine and a Policy of
ABIM. Philadelphia, PA: American Board of Internal Medicine, 1999.
6. Arnold P. Gold Foundation. Challenging the Barriers to Sustaining
Humanism in Medicine: Focus on Humanism in the Medical School
Selection Process. Alexandria, VA, June 1998.
7. Coleman CL (ed). Medical School Admission Requirements United
States and Canada 20012002. Washington, DC: Association of American Medical Colleges, 2000.
8. Tzeng OC, Jackson JW. Common methodological framework for theory
construction and evaluation in the social and behavioral sciences.
Genet Soc Gen Psychol Monogr. 1991;117:4976.
9. Green M. Theories of Human Development: A Comparative Approach. Englewood Cliffs, NJ: PrenticeHall, 1989.
10. Edwards JC, Maldonado FG, Englegau GR. Beyond affirmative action:
one schools experiences with a race-neutral admission process. Acad
Med. 2000;75:80615.
11. Kassebaum DG, Szenas PL. The decline and rise of the medical school
applicant pool. Acad Med. 1995;70:33440.
12. Mitchell KJ. Traditional predictors of performance in medical school.
Acad Med. 1990;65:14958.
13. Davidson RC, Lewis EL. Affirmative action and other special consideration admissions at the University of California, Davis, School of
Medicine. JAMA. 1997;278:11538.
14. Koenig JA. Evaluating the predictive validity of MCAT scores across
diverse applicant groups. Acad Med. 1998;73:1095106.
15. Elam CL, Johnson MM. An analysis of admission committee voting
patterns. Acad Med. 1997;72(10 suppl):S72S75.
16. Association of American Medical Colleges, AMCAS Admissions
Workstation Users Manual. Washington, DC: AAMC, 2000.
17. Edwards JC (ed). Medical school admission. Theme issue of Academic
Medicine. 1990;65:13390.

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