On the fifth floor of the Tufts University medical education building, chatter fills the hall as students file out of class. It’s the beginning of their first year in medical school, and they’ve just finished a lecture devoted to health inequities. Like many medical schools, Tufts has a dedicated population health curriculum highlighting social determinants of health (SDH), which are the context in which people are born, live and work. These circumstances have come to be recognized for their remarkable effects on the totality of a person’s health. Over the last few decades, curricula on social determinants of health have been widely developed and adopted throughout medical schools in the United States.
One of the reasons SDH are important in medical education is because patients’ social contexts have a greater bearing on their health than their biomedical contexts. To demonstrate this, instructors often point to the dramatic increase in life expectancy during the 20th century, which resulted from public health improvements, not medical advancements. However, these improvements have been spread unequally among society, which is why courses on SDH also cover health inequities. Health inequities are often viewed through the lens of education, race, income and immigration status. Students learn, for instance, that for every dollar the average white American possesses, the average Black American has just 17 cents. Students also learn that Asian Americans have the highest life expectancy, at 85.7 years, while American Indians and Alaska Natives have the lowest at 73.1 years.
To understand health inequities, instructors must help students examine the causes of such disparities. For many minority groups this includes factors such as access to healthy food, health care and safe neighborhoods. While some of these health inequities have occurred incidentally, many have been engineered from discriminatory practices. Construction of highways through communities of color, redlining racial groups to undesirable areas and discriminatory legal practices all affect health. Importantly, discriminatory hiring practices and educational policies—key parts of structural racism—work to suppress income and knowledge impacting health as well.
All this represents a marked achievement by medical schools. Nevertheless, where they fall short is by reflecting on structural racism within their own admissions practices. Legacy admissions is the hallmark of not only structural racism but also of a policy that discriminates against first-generation students and recent immigrants. Legacy admissions operates by favoring applicants that have familial ties to the university. Formally established in the early 20th century, legacy admissions policies were created to protect universities’ white, wealthy and Protestant student bodies from competing with recent European and Jewish immigrants. Today they function in much the same way, favoring the admission of white, wealthy applicants over immigrants, people of color and individuals of lower socioeconomic status.
While the ills of legacy admissions have been well recognized in the undergraduate sphere, they have failed to be appreciated in medical school admissions. Of the nation’s top 100 universities, 75 have been known to use legacy admissions. While readers may believe that they are only used in undergraduate admissions, medical schools are equally if not more culpable. Even medical schools such as Johns Hopkins, which famously eliminated legacy admissions in 2014, continue to ask applicants if they have relatives who attended or are employed by the School of Medicine. They state that this information is not used to determine interviews or acceptances. Nevertheless, concerns remain about the use of this information, who has access to it and the message it sends to applicants. What is known is that many medical schools, especially prestigious ones, do use legacy admissions when reviewing applications. While the precise algorithms for how much legacy status benefits an applicant are heavily guarded secrets, one medical school publicly shed light on it. At the University of Arizona College of Medicine, legacy applicants are granted an interview automatically, a privilege it offers to just 5 percent of total applicants. Furthermore, they go on to assert that this is in line with many medical schools, as “most have some sort of legacy process in place.”
The reason this is such a problem at the medical school level is because numerous barriers hinder applicants of color and low socioeconomic status from matriculating each year. Applying to medical school in the United States requires a bachelor’s degree, thousands of dollars in application fees, test prep and MCAT registration, in addition to hundreds of hours in studying, writing application essays and interviewing. Furthermore, inadequate connections in the medical field, insufficient knowledge of the process and prior criminal history can easily derail any progress. In contrast, applicants who come from medical families or are otherwise high income shoulder none of the financial burden of low-income applicants and often have an intricate knowledge of the process, assistance with applications and connections to medical professionals and faculty. Lastly, with acceptance rates to medical schools in the low single percentiles, even if legacy admissions does function only as a tiebreak between two applicants—as some administrators claim—it could have a monumental effect on the chances of admission and class composition.
The problem is exacerbated by the fact that physicians are between 25 and 50 times more likely to have a parent who was a physician than the average population. Research from Stanford University shows that in Sweden medicine is becoming increasingly practiced by doctors who are offspring of physicians—results they believe are generalizable to the United States. Among doctors born in the 1980s in Sweden, nearly 20 percent had a parent who practiced medicine. In the United States, the average physician’s salary amounts to $208,000, nearly four times the average American salary of $53,000. The result is not only a concentration of wealth but also of medical knowledge, which bodes poorly for first-generation and low-income students looking to break into the profession, but also for society at large.
Recently, there has been an avalanche of grassroots and institutional action against legacy admissions. Most importantly, after Johns Hopkins eliminated legacy admissions in 2014, Amherst College joined JHU in 2021. In the same year, the state of Colorado passed legislation mandating Colorado public universities to abandon the practice. Similar legislation is pending in New York as well as Connecticut. On a broader scale, congressional Democrats in February 2022 unveiled legislation to deprive universities that use legacy admissions of federal dollars. Despite these actions, almost nothing has been written on legacy admissions at the medical school level, and no medical schools have taken up the call to eliminate legacy—with Tufts University School of Medicine as the notable exception.
For decades, medical schools have advanced their curriculum to teach about social determinants of health and health inequities. It’s time they take a look at their admissions practices and assess how they contribute to structural racism and health disparities. While fair admissions won’t be achieved by this modest change, it is a small step in the right direction. Excise legacy admissions.