The diversity of medical school classes has barely budged in recent decades, even with the ability to consider an applicant’s race as one factor in admissions. Now, many medical school leaders fear a looming U.S. Supreme Court decision to restrict or ban race-conscious admissions policies could lead to precipitous declines, imperiling efforts to fight the nation’s stark racial and ethnic health disparities.
There’s good reason for concern: In the nine states where affirmative action is already banned at public universities, medical school classes are notably less diverse. But one school in California — the state with the country’s longest-standing ban on using race in admissions — has defied the odds. The University of California, Davis runs the country’s most diverse medical school after Howard, a historically Black university, and Florida International, a Hispanic-serving research university.
What Davis, and its remarkably diverse class of 2026 demonstrates, is an alternative future for a post-affirmative action world, one where diversity might be achieved despite the many obstacles that stand in the way. The student body has gone from predominantly white and male in the years before California adopted its affirmative action ban in 1996 to one in which nearly half the current class comes from Black, Hispanic, and Indigenous populations — people who have been historically underrepresented in medicine, and sometimes mistreated by its practitioners.
advertisement
It hasn’t been easy. This demographic shift has required decades of hard work, millions in funding for scholarships and new programs, and deft political skill. It’s meant pushing back against alumni, donors, and faculty concerned about the school’s reputation, national rankings, and MCAT scores, metrics that can systematically exclude students of color and those with limited financial means.
Doing anything other than revolutionizing how medical students are chosen, said Mark Henderson, the outspoken internal medicine physician who revamped the admissions process at Davis’s medical school when he took over 16 years ago, means medical schools are failing to meet their basic mission of creating the physicians the nation desperately needs — and makes those schools complicit in the inequalities that run rife through the nation’s health care system.
advertisement
“There will be ways to look like you are closing the gaps, but aren’t really,” said Henderson, who argues only a handful of medical schools are doing the work needed to diversify their classes and, through them, the nation’s health care workforce. “The fear I have is that institutions will take the path of least resistance.”
Leaders of the Association of American Medical Colleges are deeply concerned about the upcoming Supreme Court’s ruling in two cases challenging admissions policies at Harvard and the University of North Carolina. During oral arguments in October, the court’s conservative majority appeared skeptical that the programs are lawful. Lawyers for the AAMC filed a strongly worded amicus brief arguing that medical professionals, not judges, are best suited to make decisions about who will make the best health care workers, and that precluding the use of race in admissions could “potentially trigger a spiral of severe and self-reinforcing decreases in diversity in the health care professions.”
This would be harmful, they argue, because medical professions already don’t resemble the Americans they serve. According to 2018 data from the AAMC, 56% of the nation’s doctors are white, 17% are Asian, 6% are Hispanic, 5% are Black and less than half of one percent are Indigenous. (The race of nearly 14% is listed as unknown.)
Many studies suggest a more diverse workforce would help curb the nation’s staggering health disparities; research shows patients fare better when treated by health professionals from their own communities. And physicians who are Black and brown or come from backgrounds that are low-income or rural are more likely to work with medically underserved populations — jobs that can be lower-paying and more difficult.
“I can’t say this strongly enough,” Geoffrey Young, who leads the AAMC’s ambitious plan to transform the health care workforce, told STAT. “Diversity saves lives.”
The demographics of the 133 members of the class of 2026 at UC-Davis’ medical school are exceptional: 14% Black, 30% Hispanic, and 3% American Indian/Alaska Native, numbers that match or exceed the U.S. population. Perhaps even more surprising, 42% were the first in their families to attend college and 84% come from economically disadvantaged backgrounds.
These are numbers most medical schools never see. Despite decades of discussion about the nation’s overwhelmingly white physician workforce, lip-service about diversity on medical school websites, and hand-wringing among medical school deans, applicants of color confront deeply entrenched hurdles.
These structural barriers include wealth and educational inequities rooted in generations of racial discrimination: More than half of students accepted into medical school come from the nation’s top income brackets while just 5% come from the lowest. And 73% percent of successful applicants have a parent with a higher educational degree, with 20% of those parents being doctors themselves.
The MCAT, the medical school admissions test, is known to favor wealthier candidates, and is a major factor in admissions decisions though many studies show high MCAT scores do not predict success as a physician, just success at test taking. Another barrier is that many medical schools look askance at applicants who have attended community colleges, which play a critical role in the upward trajectory for many students of limited means.
“It’s just very hard to grow up Black and poor and achieve the educational background needed to be competitive in medical school,” said Henderson. “In effect, the deck is stacked against you.”
Most medical school admissions committees set up barriers for more economically disadvantaged students, he argues, by chasing after students with Ivy League pedigrees and U.S. News and World Report rankings that favor high MCAT scores.
It’s no accident, then, that top-ranked medical schools are among the least diverse. One analysis found medical schools with the highest U.S. News rankings have the lowest “social mission metric” —they graduate far fewer students from groups underrepresented in medicine or who go on to work in underserved areas. (Many top-ranked medical schools, including Harvard, which is ranked first as a medical school but 65th in diversity by U.S. News, declined to be interviewed for this article.)
This year, a number of elite medical and law schools have withdrawn from the U.S. News rankings: Some suggest the schools are withdrawing in response to the upcoming Supreme Court decision in order to be open to taking students with lower test scores. Others say the schools are trying to evade accountability regarding issues like tuition, student debt, and diversity.
All the factors that make it challenging to diversify a medical school class were in place when Henderson took over admissions 16 years ago — along with a ban on affirmative action.
That ban on state institutions using race, sex, or ethnicity for employment, contracting, or education had an immediate effect on admissions. Enrollment of Black, brown, and Indigenous students plummeted at the state’s more selective undergraduate institutions and all of the state’s public medical schools. In 1997, for example, not a single Black student was admitted into the University of California, San Diego’s incoming medical school class.
“For Native American students, it’s never recovered,” said Alec J. Calac, an M.D.-Ph.D. student at UCSD who serves as president of the Association of Native American Medical Students and recently coauthored an editorial arguing that a federal ban would erase years of progress. “You can’t create a race-blind system in a race-conscious society,” he said.
Henderson is a white man and California native who grew up in San Jose, with numerous Mexican-American friends. A fluent Spanish speaker, he’s thrilled by his state’s diversity. When he became associate dean of admissions and outreach in 2007, he found it unconscionable that his school’s medical school classes did not reflect the state’s population: The year before he started, the proportion of Davis medical students from groups underrepresented in the profession was 10%.
Davis’ particular history with affirmative action likely also played a role in his commitment to diversity, he said. In 1978, after an unsuccessful white medical school applicant sued the school, the Supreme Court ruled in a landmark case, the University of California v. Bakke, that Davis could not use racial quotas in admission, but could use race as one factor to achieve a diverse student body. (Allan Bakke was admitted, graduated, and later spent years out of the spotlight, practicing as an anesthesiologist in Minnesota.)
Henderson immediately set out to make change. “It wasn’t in vogue at the time,” said Tonya Fancher, the schools’ associate dean for workforce innovation and education quality improvement who works closely with Henderson. “I’d call it an admissions revolution.”
It may have been a revolution, but it wasn’t quick. Henderson likens the work to “Shawshank Redemption” lead character Andy Dufresne taking years to chisel an escape tunnel from his cell. While he’s now receiving national recognition, and the kudos of leaders at Davis, Henderson started his work when diversity was not prioritized. His plan involved, he said, “the slow building of things under the radar.”
He started by diversifying the admissions committee and staff. “The reason things stay the same is because everyone involved is the usual suspects,” he said.
Because Davis had to use a race-neutral approach to admissions, Henderson focused on economics. “I’d call it class-based affirmative action,” he said. “Class struggles have a huge overlap with race — that’s how we skirted the issue.” Applicants were given high marks if they had a “socioeconomic disadvantage score,” shifting admissions criteria away, he said, from MCAT scores and GPAs to characteristics like grit, resilience, and perseverance.
The school provides $12 million in scholarships each year to students who are economically disadvantaged. One statistic Henderson is proudest of: More than 40% of Davis medical students in this year’s class demonstrated enough financial need that their application fees were waived. Nationally, that number is 13%, he said.
The school places an emphasis on cultivating “hometown” physicians who come from medically underserved areas where they hope to return to practice. It started an accelerated three-year pathway for those interested in primary care — the only one in the state of California — and developed curricular options for students interested in tribal medicine, rural medicine, or working in California’s agriculturally focused Central Valley. It turns out admitting students interested in working with the underserved serves to increase diversity, Henderson said. Meanwhile, Fancher is working with community colleges to create a pathway to admit more of their students.
The school also focuses on making all students feel welcome. Nationally, students from groups underrepresented in medicine report more experiences of discrimination, unfair grading, and less access to professional opportunities and mentoring. At Davis, incoming students are paired with like-minded peers — and faculty who look like them. “They’re seeing role models doing the work they want to do, right away,” said Fancher, who is mixed race and was a first-generation college student herself.
She remains humble about the achievements at the school. “I think we still have a ways to go,” she said. “I do worry there’s still a lot of antiracism work that still needs to happen across many of our institutions — and in all phases of physician education. We need to examine our embedded systems that allow inequity, and harm, to persist.”
The question is whether other medical school admissions committees can do what Davis has done, regardless of what the Supreme Court may rule or whether they will continue to act, as Henderson puts it, as gatekeepers to the profession. A troubling new survey of medical school leaders suggests there’s strong resistance at many schools to such transformative change.
Many medical school deans and admissions directors are flummoxed, frustrated, and unsure how to proceed, according to a study published last month by Henderson, Fancher, and colleagues. They interviewed deans and admissions officers from 37 medical schools across the country, and found that — even before the new Supreme Court ruling was an issue — the “legal and policy environment overshadowed all racial and ethnic diversity work” at some of their schools.
At least two of those interviewed acknowledged the practice of giving preferential treatment to applicants related to donors or faculty members — “keeping an eye out” for them or granting them an automatic interview — is alive and well, generally favoring whiter and wealthier applicants. “Imagine how difficult it would be to say, no [their relative] is not coming,” one said.
Many also reported pressure from higher-ups to prioritize MCAT scores because they influence school rankings. “The thing that we dare not speak out,” one interviewee said, “is how do you accomplish taking students who don’t do as well on standardized exams, and balance that with the U.S. News & World Report and the reputation of the school?”
The list of challenges seems endless. Some admissions officers said diversity work was hampered by high turnover rates of leadership, interim leaders who were reluctant to make policy changes, and leaders who initially made promises to support diversity efforts but then shifted funding and attention to other priorities, such as research or new buildings. Some who worked to increase diversity in admissions confessed to high levels of stress and burnout. “I thought I was going to have a stroke my first year,” one interviewee said. “It got me on high blood pressure medications.”
Another challenge is disagreement over what the term “holistic review” — an approach espoused by the AAMC that involves considering applicants as a whole and not just focusing on academic metrics — even means.
While holistic review could be one path to greater diversity, some admissions officers say the term is so vague as to be meaningless. “It’s a buzzword,” Henderson said. “It can be whatever you want it to be. Maybe that’s OK, but it also can be a cover for not doing anything for diversity.”
The candid interviews in Henderson’s study underscore that little systematic change to admissions policies or medical school climates has been made. Some leaders said their institutions practiced “selective inclusion,” trying to have it both ways by admitting a small number of minority applicants but otherwise maintaining exclusionary application policies that boost the national reputation of their schools. Others said students from underrepresented groups had left after enrolling due to an unwelcome climate or faculty, with one medical school leader describing diversity as “just a check box … it’s just counting bodies and not really supporting folks.”
These days, Henderson and Fancher are in high demand. Last year, they hosted a summit for medical school leaders on increasing diversity. They give talks at conferences and are besieged by calls from peers at other schools asking just how they might do what Davis has.
Henderson tells them they can — but only if they put in the work, create the new programs, allocate the funding, and commit to providing the support students they admit need to succeed.
He’s not optimistic many will do what it takes. So much about medical school admissions remains tied to a status quo that seems unwilling to make the changes necessary to truly shift the racial and ethnic demographics of their students. And now the Supreme Court appears poised to make things even harder.
“I worry these numbers will continue to erode, insidiously,” Henderson said. “It’s not going to be a front page story, it’s going to be a slow unraveling.”
This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund.
