Practicing Holistic Review in Medical Education
Holistic review is a conceptual framework that encourages medical schools to consider a wide range of criteria in deciding which applicants to admit. It promotes a balanced approach to the admissions process, taking into account both the need to admit students whose Medical College Admissions Test (MCAT) scores and undergraduate grade point average (GPA) indicate they will perform well in the foundational science curriculum, with a desire to admit students whose personal attributes and life experiences are aligned with the school’s institutional mission. Initially conceived of as a way for institutions to legally pursue more racially and ethnically diverse cohorts of students, its principles support a broad conception of diversity, including sexual and gender identity, disability status, and other features of individuals’ lived experience.
Holistic review in the admissions process is used by medical schools, not only to provide medical students and faculty the benefits of a diverse learning environment, but also to address the challenges of disparate population health outcomes and uneven access to care. Holistic review has its origins in the student admissions process, but the concept has implications for the broader culture of medical education, including student affairs, graduate medical education (GME), and faculty hiring and advancement. This issue brief summarizes key topics as described in the current literature on the use of holistic review in medical education, as well as findings from a series of interviews with recognized leaders in the field who shared their experiences with implementing holistic review initiatives.
Although medical schools consider applicant criteria other than MCAT scores and undergraduate GPA, key informants distinguished this practice from a formal and systematic holistic review process. The foundation of holistic review is an institution’s mission and educational goals, which serve as the focal point for the various criteria used to both recruit and evaluate applicants, and foster a shared understanding of the rationale and goals of holistic review among the broader medical school culture and the community it serves. A critical element of holistic review is transparency in the process. Key informants emphasized that expectations for the types of experiences and specific personal attributes valued by the program, and how they reflect the institutional mission, are made explicit to all applicants. Moreover, the stated objectives of holistic review must be linked with measurable outcomes and subject to rigorous evaluation, thus providing an evidence base that can be used to validate assumptions, understand what components are effective and identify persistent challenges, and communicate findings with institutional and community stakeholders.
The conceptual framework of holistic review is expanding beyond medical school admissions. Its principles are being applied to medical school student affairs, applicant selection for residency programs, and the recruitment and advancement of medical school faculty and senior administration. Key informants reported that their programs are focused on ensuring that the expectations students have developed as a result of the institutional messaging around holistic admissions and its promotion of diversity and inclusion is consistent with the lived experience of medical education. This translates into concrete actions such as the development of risk models that help anticipate students’ need for supportive resources and coordinating the efforts of the different functional areas of student affairs to make certain those needs are met. A pilot program at the University of Texas Health Science Center at Houston demonstrated that a holistic review-based residency selection process that reduces the emphasis of Step 1 scores in favor of consensus-based, mission-aligned applicant criteria can lead to a more diverse cohort of residents without incurring significant risk to the program’s board exam pass rates. The Baylor College of Medicine is currently using a holistic review-based framework for new and ongoing medical faculty searches, and is piloting a program in which select departments will use the framework in the faculty advancement process. It is important to acknowledge that the use of holistic review in student affairs, applicant selection for residency programs, and the hiring and advancement of medical school faculty and senior administration is a newer development; there is not yet consensus on what represents best practices (nor much research on these subjects). Nonetheless, the application of holistic review in these contexts has enormous potential to transform the culture of medical education and healthcare generally.