David Acosta

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Holistic Considerations for Medical School Admissions Officers and Admission Committees Concerning Intersections of Covid-19, Racism, and Inequality.
The Advancing Holistic Review Committee at the AAMC has provided guidance to schools for over ten years on implementing and continuously improving holistic review. At this moment, the AHRC recognizes the disparate impacts of the Covid-19 pandemic, as well as the current racial climate in the US. The AHRC is particularly concerned with the intersections of racism, inequality, and Covid-19 on premedical students and medical school applicants. To that end, the committee is providing the following considerations for admissions officers and admission committees. We recognize that each school faces varied circumstances and there can be no "one size fits all" approach. We urge admission committees to have discussions about students' life circumstances and the considerations that follow in order to promote consistency, equity, and fairness for all applicants. Schools should focus their efforts on adapting policies, procedures, and admissions activities to mitigate, where possible, the adverse impacts of racism, inequality, and the pandemic on applicants.
These considerations are not intended to be used as a checklist, interview guide, applicant interview prompts, or to modify a school's existing policies on applicant privacy and the types of information a school may properly consider in making admissions decisions. Rather, these considerations are intended to expand empathy and understanding of the current and future classes of applicants and to encourage and influence discussion and reflection among admissions officers around the changes and challenges of this admissions cycle. Further, we hope these considerations inform the hand-off of the accepted cohort of students from Admissions to Student Affairs and Education Affairs so that they are aware of circumstances impacting the academic and personal preparation of the 2021 incoming class and classes in the years to come. Admissions officers should work collaboratively with Student Affairs and Education colleagues to provide the necessary resources and adapt programming to effectively meet student needs. Considering the disparate impact of the pandemic on applicants at all stages of preparation, this guidance should remain a relevant framework in holistically evaluating applicants for cycles subsequent to the pandemic.
Consider the impact of the pandemic, racism, and inequality on our medical school applicants who may be facing:
· Personal or family member illness due to COVID-19 · A health condition · Financial stress due to decrease in or loss of employment · Employment stress due to increased work or employment demands · Food insecurity · Housing insecurity or an abrupt change in housing due to income loss or campus closure · Transportation limitations due to public transportation shutdowns · Less than ideal study from home situations · Loss of reasonable accommodations for disabilities · Family members dependent on them for income or assistance with other needs · No or limited Wi-Fi · No computer and having to engage in online learning via cell phone · No or altered access to campus support resources such as printing, tutoring, library support, etc. · Loss of loved ones and lack of closure due to social distancing · Loss of mentors due to COVID-19 and/or due to social distancing · Mental health issues and stress · Disproportionate fatalities in their racial/ethnic group or community
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· Direct acts of racial hatred and discrimination against people of Asian descent due to coronavirus racism
· Direct acts of racial hatred, discrimination, police brutality, white nationalist parades, and hate crimes that endanger, intimidate, and invalidate the lives of Black applicants
· Intimate partner violence · Difficult choices about participating in community solidarity and demonstrations while navigating
personal safety and the responses of law enforcement on and off campus
In a holistic review process, schools look at a potential medical student's Experiences, Attributes, and Metrics (EAMs) to widen the lens through which we assess applicants in support of school mission and to further leverage the benefits of diversity, equity, and inclusion. For the upcoming admissions cycle, and cycles to come, we must consider the downstream effects of the pandemic, racism, and inequality on students' abilities to meet criteria for admission that are beyond their control. Below are some specific examples to help guide your thinking as an admissions officer. These examples are not meant to cover every scenario but can serve as a starting point for discussions with your admission committee to consider.
Experiences
The capacity of applicants to engage in experiences may be severely limited or eliminated. Programs for service, enrichment, or healthcare exposure may be cancelled or adapted for virtual delivery. Virtual delivery may impact a student's ability to learn, develop genuine connections, or meaningfully engage in an experience. Letters of evaluation may also be adversely impacted by the lack of access, or virtual access to experiences. Transportation, equipment, and Wi-Fi access may greatly impact a student's ability to participate in experiences. Many universities closed research labs and suspended research activities, cancelled or scaled back summer recruitment programs, suspended shadowing and health coaching programs, and limited mentorship resources.
Community Service: School-supported or independently sought community service opportunities may be limited or non-existent. Additionally, students who are supporting themselves or family members financially and/or who have suffered employment loss may not be able to dedicate time to service activities. Students from more privileged backgrounds may have the means to create service opportunities for themselves. While we recognize some students will be able to go above and beyond during this crisis, it is critical that we continue the holistic review practice of evaluating each applicant in context.
· Not everyone can take advantage of or create service opportunities at this time · Emphasize evaluation of interpersonal and intrapersonal competencies gained from service-oriented
experiences rather than time-based measurements · Be explicit that community service experiences will be viewed in context with the understanding that
the pandemic may have had an impact · Value candidates who create service opportunities for themselves and others without penalizing
candidates who do not
Healthcare Experience: Students may not be able to meet the number of hours normally required or recommended to be considered for your school. Consider, among other possibilities, evaluating healthcare experience from the lens of competency rather than hours. Can the student describe what a physician does? Does the student have an appreciation for what a career in medicine entails?
· Add narrative prompts to your secondary application to gather this information · Broaden acceptance of medically related experiences beyond shadowing such as being the primary
caregiver for a member of the family that has COVID-19 related illness and/or being the primary
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language translator/interpreter/cultural broker for a member of the family when contacting their English-only speaking physician for advice and treatment (in-person or via telehealth). · Be explicit that healthcare experiences will be viewed in context with the understanding that the pandemic may have had an impact
Research Experience: Students may not be able to meet the number of research hours normally required or recommended to be considered for your school. Consider, among other possibilities, evaluating alternative forms of experience such as submission to peer reviewed journals, independent research, or science tutoring.
Advising Experience: Committees are already aware that student access to supportive, expert prehealth advising is unequal. Certain aspects of advising and prehealth committee protocols may exacerbate underlying inequalities. Students may not have advising resources to guide them about how to approach explaining the loss of experiences or impacts of the pandemic, racism, or inequality on their preparation.
Institutional Actions and Criminal Histories: Students may be socially and interpersonally impacted differently due to mask-wearing protocols required because of the pandemic. Students may choose to participate in demonstrations or solidarity activities on or off campus that may result in institutional action or arrest. Racism and inequality may have disparate impacts on students in the aftermath of participation.
· Students of color and low-income students may not have legal resources to advise them on situations of arrest or detainment.
· Institutional actions of academic probation may be more prevalent due to pass/fail courses, or course performance decrements related to the aforementioned stressors.
· Students may face challenges on or off campus in navigating rules and regulations for demonstrating or advocating for change.
Attributes
Race/Ethnicity/Ties to a Marginalized Community: Students may be experiencing the impacts of the pandemic, racism, and inequality in disparate ways related to their racial or ethnic identities, communities of origin, gender identity, and/or sexual orientation. Committees should consider the disproportionate losses for communities of color and the disparate impacts of racism and social inequality for students. Not everyone feels safe in every context. Different communities have been impacted in various ways. Racism and inequality may impact how students navigate their continued preparation.
Socioeconomic Status: The economic status of students and their families may have changed significantly from their last tax return and, given recent job losses, may not be reflected in the indicators on the application (EO1 or EO2). Bear in mind the means by which each indicator is derived on the AMCAS application. Students may be facing hardship that is not reported in their applications.
· EO1 and EO2 are based on parental education and occupation reported by the applicant · First generation is self-reported · Disadvantage is self-reported · Family income level is self-reported · Fee Assistance Program (FAP) eligibility is verified by AMCAS staff and is usually 300 percent of the
Federal Poverty Level (FPL) for household size. For this cycle, the Fee Assistance Program (FAP) will be 400 percent of FPL.
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Disability: Students with school-provided services, accommodations, and support may have little or no access to these resources during the pandemic. These include learner supports such as closed captioning, notetaking, and private testing accommodations that are difficult to provide for online courses.
Consider adding questions to your secondary application about COVID-related changes or impacts. Sample questions available here.
Metrics
MCAT Scores: The belief that applications need to be submitted on June 1st puts unnecessary pressure on premedical students and with MCAT testing being delayed for some students, there will be lag time until all applications are complete. Consider the following, among others, for discussion at your school:
· Assure students that they do not need to submit on June 1st · Use the possible delayed data transmission as an opportunity to strategize how to conduct a more
holistic assessment of applicants · Begin the review process for applicants with pending MCAT scores · Release secondary applications to everyone who meets other requirements while clearly
communicating the EAMs that have been considered in the past. Or post your secondary application questions to your website so that students can prepare their answers while waiting for their MCAT scores in the event that some applicants experience a delay
GPA: Students may have some pass/fail grades and/or online coursework. The pandemic may adversely impact a student's ability to achieve their normal standard of performance. Students should not feel pressured to elect graded options when they are in distressed situations. Additionally, dips in GPA add confounding factors to the evaluation of academic preparedness. See AMCAS resources on alternative grading here. Consider communicating that you will accept pass/fail coursework without prejudice. See call to action here. Encourage your committees to continue to view metrics within applicant context.
· Recognize students may be dependent on their enrollment status for access to important resources such as campus-sponsored health insurance or counseling center access. This may preclude students from withdrawing due to performance concerns.
· Students who are under-enrolled or who may not be able to demonstrate satisfactory academic progress may also experience adverse impacts on financial aid.
Letters of Recommendation: The pandemics may also adversely affect student performance in ways that then appear in their letters of recommendation. If an applicant's letters question their effort, motivation, attentiveness, or other subjective factors, encourage your committees to consider the letter(s) within the applicant context and the potential impact of the pandemics. Other factors that may impact letters of recommendation include:
· A lack of strong relationships with faculty due to extended virtual course delivery. · Inability to and or delays in getting a strong letter of recommendation due to campus closures and
instructors being impacted by COVID-19.
Travel and Interviews
Conducting in-person interviews may not be feasible for some applicants and may create additional stress for other applicants who are financially impacted by the pandemic. Additionally, depending on the geographic location where the student lives and where the school is located, travel may expose them to unnecessary risk of contracting the coronavirus. There may be applicants who are immunocompromised or who have
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vulnerable individuals in their households. Applicants experiencing symptoms who need to postpone interviews may incur additional cost if they have to reschedule travel plans.
If you conduct virtual interviews, consider the following, among others, for discussion at your school: · Ensuring that all interviewers have recently taken unconscious bias training. A free online seminar from AAMC is available here. · That the interview process is structured or semi-structured and that all interviewers are asking a carefully crafted set of interview questions to reduce the risk of conscious or unconscious bias. · Asking all candidates about technological capabilities for Wi-Fi and adequate device support. · Evaluate resources at your disposal to address these disparities in technology in advance. · Asking all candidates about private, quiet space to conduct a video interview. · Evaluate resources at your disposal to address any private space issues in advance. · Consider technology accessibility for applicants requesting accommodations due to disability. · Provide all candidates guidance on how to set themselves up for a successful video interview. · Include an explicit code of conduct for interview participants, such as expectations about phone use, private space, attire, background, etc. Notify interviewees of conduct expectations in advance, with time to address any gaps and/or seek alternative accommodations. · Prepare in advance for applicant needs around rescheduling due to unforeseen personal or technology issues. · Recommendations and tips for conducting virtual interviews can be found here. · Visiting the campus and community provides an opportunity for applicants to assess climate and inclusion, especially for underrepresented students. If conducting virtual interviews, provide opportunities for candidates to have current student interactions that typically accompany in-person interviews. · If you are conducting virtual interviews, consider doing this for the entire season so that the process is equitable for all applicants.
Extending the Conversation
The hand-off from Admissions to Student Affairs and Education post-acceptance should consider the importance of empathy in the holistic review process for this cycle and future cycles impacted by the pandemic, racism, and inequality. We must be even more intentional and robust in our communication between Admissions to their Student Affairs and Education colleagues to raise awareness and empathy of the aforementioned challenges and circumstances faced by the incoming class that were considered during the admissions process to inform proper supports are in place for students as needed, as early on as possible.
Acknowledgements
The AAMC would like to acknowledge and thank Leila Amiri, PhD, Assistant Dean for Admissions and Recruitment at the University of Illinois College of Medicine, Christina Grabowski, PhD, Associate Dean for Admissions and Enrollment Management at the University of Alabama at Birmingham School of Medicine, and Sunny Nakae, PhD, Associate Dean for Student Affairs at the University of California Riverside School of Medicine, whose experiences and suggestions led to the creation of this document. We would also like to acknowledge the Group on Student Affairs Committee on Student Diversity Affairs and Committee on Admissions and the Holistic Review Advisory Committee for providing support and valuable input for this document. Special thanks to Dr. Nakae and O'Rese Knight, MD, University of North Carolina at Chapel Hill for their expertise in refining and finalizing this guidance.
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