Numerous medical schools have made news in recent years by offering free tuition, but that might not be enough to bolster diversity in medicine. It is also necessary to reduce the costs of applying to medical school, say authors of a perspective published online today in the New England Journal of Medicine.
Application fees; interview costs including clothing, transportation and lodging; test fees; and test preparation fees may keep qualified students from taking the first step, write Lorena Millo, BS, with the Margolis Center for Health Policy at Duke University in Durham, North Carolina, and colleagues.
"High application costs send a message that medical education isn't designed to be obtainable for low-income people, which could potentially deter some people from applying at all," they write.
While some schools are expanding scholarship programs and even waiving tuition costs altogether, Millo and colleagues note that similar improvements have not come to the application process.
And whereas medical school costs come with the high odds of making enough money as physicians to repay the debt, the application process requires a much bigger gamble.
Just taking the Medical College Admission Test (MCAT) costs $315 and 62.7% of students taking it buy practice exams that cost between $2000 and $10,000, the authors write.
In addition, most schools require a primary application using the American Medical College Application Service system, which costs $170 for the first school and $40 for each additional school. Secondary application fees can be as high as $200, the authors explain, noting that in 2018 applicants submitted a median of 15 secondary applications.
Millo and coauthors argue the application costs may help explain low numbers of underserved populations among the 2018 applicants.
"In 2018, only 9% of applicants identified as black or African American, 10% as Hispanic, and less than 1% as American Indian or Alaska Native," the authors write. "Nearly a quarter of first-year medical students come from families earning $250,000 or more per year, whereas only 5% come from families in the lowest household-income quintile (with incomes of about $24,000 per year or less)."
Increasing costs for applying come as average medical student debt rose to $200,000 last year, the authors note, a 4% increase over the previous year.
The authors point to two sources that help with application costs: hosting programs in which current medical students host applicants so they don't have to pay for a hotel, andthe Fee Assistance Program (FAP) run by the Association of American Medical Colleges (AAMC). That program reduces the MCAT cost, waives primary-application fees for up to 20 schools, and supplies free MCAT-prep materials. Additionally, most schools also waive secondary fees for those who qualify.
But the help does not go far enough, the authors write. It doesn't extend to interview costs, for one thing, and it doesn't help people who may not qualify by income but still can't afford the costs.
The costs can be a barrier, agreed Valerie Parkas, MD, senior associate dean of admissions at Icahn School of Medicine at Mount Sinai in New York City. In addition to the expenses listed in the article, she adds that doing the research, clinical work, and volunteer work to develop an application that's competitive can also be a barrier for those with fewer resources.
"I think for economically and educationally disadvantaged students, the whole process is more challenging," she told Medscape Medical News. That said, individual schools and the AAMC are actively working to achieve more equity in applications.
At Mount Sinai, for example, medical students host medical school applicants and alumni host applicants for residencies. The school also waives secondary fee applications and tries to accommodate those who want to interview on a day they are already interviewing in the area so as to avoid additional flights to the same region.
The school also has an early-assurance program called FlexMed, which allows 40 to 50 sophomores to know they are accepted so they don't have to go through the usual application process or take the MCAT.
"We also have an early assurance for our residency program for our students who know what field they want to get into," Parkas said. "They don't have to apply broadly for residency, again taking away all the travel and application fees."
Millo and coauthors offer three ideas for change. One is limiting the number of schools to which applicants could apply to level the field for those of different incomes.
The second is asking medical schools to screen applicants more thoroughly before inviting students to submit secondary applications. Currently, students are spending money to send secondary applications without knowing that the schools consider them serious candidates.
A third option is for schools to conduct virtual interviews, they write.
Each of these options has pros, Parkas says, but also cons.
Limiting the number of schools for applicants may disadvantage those who have not had as much access to advisers and mentors who could help them skillfully narrow their school choices, she said.
"I think that's worrisome," Parkas cautioned.
Virtual interviews are worth thinking about but they have a downside, she said. "You want students to see the school, get a sense of the learning climate, the culture of the school, talk to students, visit the city, and know if it feels like a 'good fit.'"
As to schools being more selective about secondary application invitations, Parkas said that recommendation probably makes the most sense.
However, she said, there are schools with so many applications they may turn to metrics as a way to be more selective in a short period of time and that may have the opposite effect of what the authors are promoting.
"Students who might have real adversity and reasons for academic challenges might not get a full holistic review," she said. "That may disadvantage the disadvantaged."
The authors and Parkas have disclosed no relevant financial relationships.
NEJM. Published online October 16, 2019. Perspective
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