Free tuition won’t fix medicine’s diversity problem without admissions reform

Medical students at Albert Einstein School of Medicine in New York City gathered last week to hear a life-changing announcement: Ruth Gottesman revealed she would be donating $1 billion, ensuring no student at Einstein will pay tuition ever again.

Leadership at Albert Einstein School of Medicine celebrated the donation as a means to attract a more diverse student body. Improving diversity in the nation’s physician workforce is a public health imperative. Forty years of affirmative action policies were unable to compensate for the devastating impact of the 1910 Flexner Report, which led to the mass closure of medical schools that admitted Black students, and an estimated loss of 35,000 Black physicians into the field. Despite the urgency of improving diversity in our physician workforce, the number of applicants from Black, Hispanic, and other underrepresented groups in medicine being admitted to medical school has decreased in the United States. Black/African American, low-family income, and first-generation students are less likely to be admitted to M.D.-Ph.D. programs, despite being as qualified or more qualified than other applicants. In trying to explain these gaps, as well as the shortage of students interested in entering primary care, experts often point to the high cost of medical school. But the truth is more complicated than that. Simply going tuition-free cannot address entrenched issues of racial and socioeconomic disparities in medical school admissions.

New York University School of Medicine announced at its 2018 White Coat Ceremony that it would become tuition-free. The change was similarly hailed as beneficial for expanding student body diversity and the primary care workforce. While the number of applications to NYU’s medical school increased by 47% between 2018 and 2019 and applications from students from underrepresented groups rose by 102%, the percentage of matriculants at NYU who identified as Black/African American has averaged just below 11% between 2019 and 2022, down from 14% in 2017.

NYU’s matriculating student MCAT range narrowed from 506-528 in the 2017-2018 admissions cycle to 516-527 in the 2022-2023 admissions cycle, and their accepted GPA range narrowed from 3.45-4.0 to 3.62-4.0 in the same time frame. Thanks at least in part to this increased selectivity, their U.S. News and World Report Ranking rose from No. 11 in 2018 to No. 3 in 2019. In addition, no students in NYU Grossman School of Medicine’s inaugural tuition-free class, who matriculated in fall 2018 and graduated in 2022, matched into family medicine. Three students from the class that matriculated in fall 2019 matched into family medicine in 2023, and the number of students matching into pediatrics decreased from 10 in 2022 to six in 2023.

Tuition-free medical school has also been suggested as an intervention to improve the financial diversity of medical school matriculants, which may contribute to increased enrollment by people from groups underrepresented in medicine. A study found that between 2017 and 2019, one-quarter of student doctors reported a family income in the top 5% of income earners, while the percentage of students from the lowest household income quintile has never exceeded 5.5%.

Relieving the burden of student loan repayment does nothing to address the link between wealth and medical school admissions in the United States. Applicants reporting a family income of less than $50,000 are 48% less likely than applicants reporting a family income of $200,000 or greater to be accepted into an M.D. program, most likely because medical school admissions policies heavily favor wealthy applicants. Wealth facilitates applicants’ participation in unpaid activities such as shadowing, volunteering, and clinical research, while family income is linked to success in college admissions and on the MCAT. After NYU became tuition-free, the percentage of students who self-reported as financially disadvantaged fell from 12% in 2017 to 3% in 2019 and has remained between 3% and 7% since.

Relief from student loan debt for medical students should be celebrated. However, absent any additional interventions it is unlikely to substantially improve the racial, ethnic, and financial diversity of our physician workforce. The nullification of affirmative action policies in the United States presents an additional challenge, but not an insurmountable one, as is evidenced by the University of California at Davis’ success in achieving representation that matches or exceeds the United States population. (California has prohibited state institutions from using race or ethnicity for admissions decisions since 1996.) The UC-Davis admissions committee focuses on socioeconomic disadvantage, which is deeply interwoven with race in the United States through centuries of racial violence and disenfranchisement.

Addressing racial bias and socioeconomic disadvantage will require a shift away from traditional admissions metrics. Medical schools could deemphasize the MCAT, an exam known to favor white, wealthy applicants, or prioritize applications from community college graduates, a cohort of diverse students with a high prevalence of intention to work with underserved communities. Because the process of applying to medical school unfolds over several years, the expansion of pathway programs for students from underrepresented groups is essential to provide mentorship, networking opportunities, and academic support to counteract the interpersonal discrimination that adversely affects students of color. (Pre-medical students from underrepresented backgrounds, for instance, experience greater discouragement from their pre-health advisors than their white counterparts.) As gatekeepers to the profession, medical school admissions committees and pre-health advisers must confront their own biases and embrace a holistic admissions approach that considers hardships experienced by applicants.

These interventions will require not only a financial investment on the part of medical schools but also an investment in changing perceptions of what it means to be a “qualified” applicant.

One of us is now a resident physician, and the other is currently in medical school. We are thrilled for the students at Albert Einstein School of Medicine who will benefit from Ruth Gottesman’s generosity. But as people celebrate, we hope they will realize that there is no single fix — even one as significant as free tuition — for the complex issues of racial, ethnic, and socioeconomic disparities in medical school admissions.

Tricia Pendergrast, M.D., is a resident physician in the Department of Anesthesiology at the University of Michigan. Jared E. Boyce, ScM, is an M.D.-Ph.D. candidate in the Medical Scientist Training Program at the University of Wisconsin School of Medicine and Public Health.