Holistic Review in Health Professions: Impact on Diversity and Academic Success, Study notes of Medicine

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Holistic Admissions in

the Health Professions

FINDINGS FROM A NATIONAL SURVEY

SEPTEMBER 2014

This project was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (NIH), Award Number U24MD006960, with additional funding support provided by the Health Resources and Services Administration (HRSA). Publication and report contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or HRSA.

Suggested Citation:

Glazer, G., Danek, J., Michaels, J., Bankston, K., Fair, M., Johnson, S. & Nivet, M. (2014). Holistic admissions in the health professions: findings from a national survey. Urban Universities for HEALTH. Washington, DC.

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Preface

Urban Universities for HEALTH is a partnership effort of the Coalition of Urban Serving Universities (USU)/Association of Public and Land-grant Universities (APLU), the Association of American Medical Colleges (AAMC) and the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities (NIMHD). The project aims to improve evidence and the use of data that will help universities enhance and expand a culturally sensitive, diverse and prepared health workforce with the goal of improving health and health equity in underserved urban communities.

As leaders of Urban Universities for HEALTH, we are proud to present this report to our colleagues and the university community. University leaders have a unique ability to shape the health workforce through their admissions policies. The National Study on University Admissions in the Health Professions is the first to examine the impact of admissions strategies across multiple health professions on a national scale. This study supports the work of Urban Universities for HEALTH by providing new data regarding a promising admissions practice intended to improve diversity in the health workforce.

We hope that university leaders and health professions deans will benefit from this study as they design their admissions processes to promote access to education in the health professions and increase success for all students. Insights from this report will also be of use to national health professions and higher education associations, federal agencies, and other organizations working to reduce health disparities and build a health workforce that better meets the needs of communities.

Betty Drees, M.D.

Betty Drees, M.D. Co-Principal Investigator, Urban Universities for HEALTH Dean, College of Medicine, University of Missouri-Kansas City

Roderick Nairn, Ph.D. Co-Principal Investigator, Urban Universities for HEALTH Provost, University of Colorado Denver Anschutz Medical Campus

Marc Nivet, Ed.D., MBA Co-Principal Investigator, Urban Universities for HEALTH Chief Diversity Officer, Association of American Medical Colleges (AAMC)

Jennifer C. Danek, M.D. Senior Director, Urban Universities for HEALTH Coalition of Urban Serving Universities (USU)

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Acknowledgements

Urban Universities for HEALTH would like to thank many individuals and organizations for their contributions. First, we would like to recognize Julia Michaels at APLU/USU for leading the survey design and data analysis and for assistance with developing the final report, and Angela Clark, from the University of Cincinnati team, for leading the qualitative research design and analysis. Jun Ying from the University of Cincinnati and Taniecea Arceneaux provided helpful statistical advice. Special thanks to Shari Garmise at APLU/USU and Malika Fair at the AAMC for their leadership, and Sherese Johnson at the AAMC for facilitating distribution of the survey.

We would like to thank the AAMC Advancing Holistic Review Initiative team, including Henry Sondheimer, Liz White, and Amy Addams for their invaluable advice over the course of the project, and Kim D’Abreu from the American Dental Education Association (ADEA) for assisting with outreach. We appreciate Judith Sondheimer for copyediting assistance.

We would like to thank the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities (NIMHD) and the Health Resources and Services Administration (HRSA) for financial support of the project.

The USU Health Action Group on Admissions was responsible for developing the action item that led to this study, and we appreciate the insights of those individuals, especially Jorge Girotti, Christina Goode, Naty Lopez, Ann Christine Nyquist, Linda Scott, and Andrea Wall. We thank the USU Health Steering Committee for providing strategic oversight and the Urban Universities for HEALTH demonstration site teams for their feedback.

We are especially indebted to Santa J. Ono, President of the University of Cincinnati, and M. Roy Wilson, President of Wayne State University, who have been important champions for the USU’s health agenda, and provided invaluable support for this study. Charles Bantz, Chancellor of Indiana University-Purdue University Indianapolis, Mark P. Becker, President of Georgia State University, Darrell G. Kirch, President and CEO of AAMC, and Peter McPherson, President of APLU, are also acknowledged for their leadership and support.

Finally, this project would not have been possible without the contributions of the university presidents and chancellors whose institutions participated in this study and the many health professions deans and admissions directors who completed the survey.

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Introduction

Universities are facing increased pressure to graduate students who will succeed in the workforce and meet changing labor market demands. This need is particularly urgent in the health professions. Growing health workforce shortages, a rapidly diversifying patient population, and transformative changes to the health care system have combined to create new challenges for universities with health professions schools. University and health leaders are increasingly concerned with preparing graduates who possess the personal qualities, professional skills, and experiences to be successful in the workforce while also satisfying the health needs of the communities they serve.

In order to achieve this goal, many universities have begun making changes not only to their curricula and learning environments, but also to the practices used to select students for admission. With the growing recognition that standardized test scores and GPAs do not capture the breadth of experiences and personal qualities that an applicant brings to the university and the profession, many universities have begun to incorporate “holistic review” into the admission process, with the goal of admitting a diverse body of students that will not only excel academically, but will also have the qualities needed for success in the current work environment.

WHAT IS HOLISTIC REVIEW?

Holistic review is a university admissions strategy that assesses an applicant’s unique experiences alongside traditional measures of academic achievement such as grades and test scores. It is designed to help universities consider a broad range of factors reflecting the applicant’s academic readiness, contribution to the incoming class, and potential for success both in school and later as a professional. Holistic review, when used in combination with a variety of other mission-based practices, constitutes a “holistic admission” process.

In 2003, the U.S. Supreme Court officially described the strategy as a “highly individualized, holistic review of each applicant’s file, giving serious consideration to all the ways an applicant might contribute to a diverse educational environment”(Grutter v. Bollinger, 539 U.S. 306, 2003). The Association of American Medical Colleges (AAMC) further refined this definition to provide specific guidance to medical schools, stating that in a holistic review process, “balanced consideration is given to experiences, attributes, and academic metrics

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USE OF HOLISTIC REVIEW IN THE HEALTH PROFESSIONS

Many colleges and universities currently use a holistic admission process to select students. The practice has become more popular in health fields such as medicine, because it permits evaluation of a broader range of criteria important for student success, and the selection of individuals with the background and skills needed to meet the demands of a changing health care environment. The Association of American Medical Colleges (AAMC) Advancing Holistic Review Initiative (previously the Holistic Review Project) has provided critical initial steps in enabling medical and other health professions schools to conduct holistic review, by translating abstract legal and educational policy concepts into implementable and assessable practices. The AAMC convened its Holistic Review Committee in 2007 and piloted its first Holistic Review in Admissions workshop with 10 member institutions in 2010. Similar workshops have been conducted in dentistry since 2009 by the American Dental Education Association (ADEA). Other professions have joined medicine and dentistry in adopting holistic review as well. The Coalition of Urban Serving Universities (USU) member survey of 2011 indicated that many USU member health professions schools had transitioned to a holistic admission process (Coalition of Urban Serving Universities, 2011).

Universities often implement holistic review with the intent of increasing the diversity of their student bodies and developing a campus culture that values diversity and inclusion. The need for diversity is particularly important in the health professions, where lack of diversity among professionals may contribute to disparities in access to health care and services for minority populations. Access to care is often limited in areas heavily populated by ethnic minorities and immigrant communities (Smedley, Stith, and Nelson, 2003). Minority providers currently care for the bulk of minority patients in the United States and play a larger role than non-minority providers in treating patients in poor health (Edwards, Maldonado, & Engelgau, 2000; Terrell & Beaudreau, 2003; Komaromy et al., 1996; Marrast, Zallman, Woolhandler, Bor, and McCormick, 2013). Language and cultural barriers limit providers’ ability to serve the needs of minority patients in ways that are linguistically and culturally relevant (Kirch, 2012; Manetta et al., 2007). Having medical providers similar to patients in important dimensions of identity (e.g. race, ethnicity, language) enables effective communication and improves the provider- patient relationship (Ferguson & Canbib, 2002).

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Research also shows that when groups of students with different backgrounds and perspectives are brought together, there is a positive impact on all students’ attitudes regarding access to care and an increase in the number of students who indicate an interest and intent to work with the underserved (Saha et al., 2008). Educating students in environments that value diversity and inclusion produces graduates better prepared to practice in underserved communities and whose understanding of the cultural needs of patients improves patient satisfaction and trust.

In order to achieve the full benefits of diversity, deliberate attention is paid to the institutional conditions in which that diversity is realized. Specifically, faculty must be prepared to incorporate diversity into their pedagogy and curriculum. While diversity is an important first step in enhancing the educational environment of a campus (Milem, O’Brien, and Bryan, 2013), it should not be viewed as the end goal, but rather an important means toward achieving key educational and workforce goals, as defined by the institution in its mission (Addams et al., 2010; Coleman et al., 2008; Gurin et al., 2002; Milem, 2003; Milem, Chang, and Antonio, 2005; Milem, Dey, & White, 2004).

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BOX 2. PRIOR RESEARCH HIGHLIGHTS

In 2001, the Robert Wood Johnson Foundation convened a number of dental schools through the Pipeline, Profession and Practice: Community Based Dental Education Program (Pipeline) to help address disparities in dental care for underrepresented and underserved populations. Holistic review was defined as a key component of each school’s participation (Dental Pipeline, 2010). Admissions committees were encouraged to review applications for admission with special attention to factors contributing to each institution’s mission and goals and to factors that might relate to a student’s potential for future success, such as life experiences, motivation, and ability to work through challenging circumstances. Dental schools adopting this approach saw an increase in compositional diversity, and this framework has become the foundation for holistic review in dental school admissions (Price & Grant-Mills, 2010).

In 2003, the Boston University School of Medicine began the process of transitioning from a traditional admissions process that emphasized grades and test scores to a more holistic admission process. It took nearly five years to complete the implementation, during which the school crafted a mission statement for admissions, operationalized the mission statement into decision-making criteria, re-structured its interviewing procedures, and provided faculty and staff with comprehensive training on the new process. By 2012, the school found that the characteristics of their incoming classes had changed dramatically. The share of students traditionally underrepresented in medicine increased from 11 to 20 percent. The average GPA of the incoming class increased nearly one-tenth of a point. The average Medical College Admission Test (MCAT) score increased by almost two points. Furthermore, faculty noted that students were more engaged with the community, more collegial, and more open to new ideas and perspectives (Witzburg and Sondheimer, 2013).

Although there has been some research on the impact of holistic review on medical, dental and undergraduate schools, the literature contains few reports or descriptions of the use of holistic review and its impact in other health professions such as nursing, pharmacy, and public health. The National Study on University Admissions in the Health Professions aims to address this gap.

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Methodology

SURVEY PURPOSE

The purpose of the survey was to determine the extent to which health professions schools at public universities in the United States have adopted holistic review. We wished to determine whether schools making a change to holistic review in the last decade had experienced an increase in diversity of their incoming classes, and if there were any measureable changes in the academic quality of incoming students, in student retention, or in measures of student success since adoption of holistic review practices. Finally, we wanted to gain a better idea of how health professions schools nationwide are currently evaluating their admissions practices.

SURVEY DESIGN

The researchers developed a survey instrument designed to assess admissions practices and student outcomes based on existing admissions literature. Survey content was validated by a panel of university admissions experts in medicine, dentistry, nursing, pharmacy, and public health. The panel also included undergraduate advisors for students planning careers in health as well as national experts on implementation of holistic review practices. The survey questionnaire included four sections: I) Mission, Goals, and Admissions Practices; II) Screening Processes and Criteria; III) Use of Holistic Admissions and Outcomes; and IV) Special Programs. The survey instrument contained a total of 46 questions, which included both multiple-choice and short-answer questions. With some exceptions, respondents were required to select an answer choice. The survey was piloted at a select number of institutions prior to its launch.

ASSESSING USE OF HOLISTIC REVIEW

The researchers took a dual approach to evaluating use of holistic review. First, schools were questioned about their use of a number of admissions practices consistent with holistic review that are supported by existing literature (see Table 1). Second, schools were asked toward the end of the survey to identify themselves as either having or not having transitioned to a more holistic admission process within the past ten years.

The schools’ use of practices consistent with a holistic process was scored, and scores were combined into an overall “holistic review score” from 1-10. Schools with high holistic review scores (8-10) were considered to be using many elements of holistic

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are not a comprehensive list of all holistic review practices, and we recognize that schools may have developed different approaches to holistic review over the years that may not have been captured by the survey. Finally, the survey assessed information on admissions practices and use of holistic review only among schools of medicine, dentistry, nursing, public health, and pharmacy. While holistic review is used in other health professions, this data may not be directly applicable to other health professions.

TABLE 1. HOLISTIC REVIEW SCORING MODEL

EXPLANATION OF THE MODEL The Holistic Review Scoring Model assesses schools’ use of practices consistent with theoretical principles governing implementation of holistic review that are identified in the existing literature (Wells et al., 2011; Monroe et al., 2013; AAMC, 2013). Practices span the admission process, including the approach to evaluating applicants’ files as well as other admission practices designed to fulfill a school’s mission or goals. The types of criteria included in the model are broad including, but not limited to, a school’s mission for increasing diversity. A high holistic review score (8-10) indicates schools are using many of these practices; schools with a mid-range holistic review score (4-7) are using some practices, and schools with a low holistic review score (0-3) are using few or no practices. The model was validated using a control group of schools well known for their use of holistic review.

MODEL PRACTICES ASSESSED^5 Does the institution evaluate applicant criteria related to specific mission or goals of the school (e.g. primary care, research mission, global health, urban or rural focus) Does the institution have a mission statement for admissions that includes diversity Does the institution consider non-academic criteria as well as academic metrics such as GPA and test scores in the initial screening process By what means and to what extent does the institution evaluate non-academic criteria related to student background or experience in the initial screening (e.g. first-generation status, socioeconomic status, gender, race, foreign language ability, community of origin) Does the institution select students from the waitlist by characteristics related to school’s mission or goals Does the institution provide training for the admissions committee related to school mission and/or diversity CATEGORY SCORE RANGE Many elements of a holistic process 8- Some elements of a holistic process 4- Few or no elements of a holistic process 0-

5 The practices used in our practice-based assessment are not a comprehensive list of holistic review practices, nor would it be expected that any university would adopt all components.

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Results

THE LAST DECADE: USE OF HOLISTIC

REVIEW IN THE HEALTH PROFESSIONS

Sixty-seven percent of health professions schools responding to the survey reported having changed to a holistic admission process within the past 10 years, and 8 percent indicated that they had used a holistic admission process for more than 10 years.^6 Use of holistic review varies by field, with more frequent use reported among the surveyed medical and dental schools and less frequent use among the nursing schools surveyed (Figure 1).

FIGURE 1. USE OF HOLISTIC REVIEW (N=171)

Percent of schools that self-report using holistic review, by primary degree program

0

10

20

30

40

50

60

70

80

90

100

DDS/DMD MD

Percent

Primary Degree Program

MPH PharmD BSN

82%

93% 91%

78%

47%

HOLISTIC REVIEW MODEL RESULTS

ON EXTENT OF PRACTICES

Using the practice-based model described in Table 1 we found differences in the extent to which schools that self–identified as using holistic review are implementing specific holistic review practices. According to the model, 38 percent of the schools self-identified as using holistic review in the past decade are using “many elements” of a holistic admission process, 48 percent have adopted “some

6 The majority of schools using holistic review for more than 10 years are medical schools.

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FIGURE 2. MODEL RESULTS

Extent of Use of Holistic Review: Schools Self-identified as Using Holistic Review

Percent of health profession schools self-reporting use of holistic review that are using many elements, some elements, or few to no elements from the practice-based model (N=171)

Percent of health profession schools that self-report not using holistic review that are using many ele- ments, some elements, or few to no elements from the practice-based model (N= 57)

38% Many elements

2% Many elements

14% Few to no elements

67% Few to no elements

48% Some elements

31% Some elements

Extent of Use of Holistic Review: Schools Self-identified as Not Using Holistic Review

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TABLE 4. CORRELATION BETWEEN HOLISTIC REVIEW SCORE AND INCREASED DIVERSITY

VARIABLES r T(130)

TWO- TAILED P-VALUE^8 M SD RANGE Holistic Review Score^9 Increased Diversity of the Incom- ing Class^10

0.1902* 2.2087 0.0289 0.66 0.24 0-

ACADEMIC SUCCESS Among schools self-identified as using a holistic admission process, the majority reported that measures of student success over the past decade were unchanged or improved (see Figure 3). The schools using holistic review were asked to report changes to the following measures^11 of student success including:   (^) ACADEMIC QUALITY OF INCOMING CLASSES. Measures of incoming class quality were largely unchanged or improved. Over the past decade, 90 percent of the schools using holistic review reported that the average GPA of the incoming class remained unchanged or increased, while 10 percent reported a decrease. Eighty-nine percent reported that average standardized test scores for incoming classes remained unchanged or increased, while 11 percent reported a decrease.   (^) STUDENT RETENTION. Ninety-six percent of the schools using holistic review reported that graduation rates were unchanged or increased, while only 4 percent reported a decrease.   (^) STUDENT ACADEMIC PERFORMANCE. Measures of student academic performance were largely unchanged or improved. Ninety-seven percent of schools reported that the average GPA of the graduating class was either unchanged or increased, while only 3 percent reported a decrease. Ninety-one percent of schools reported that the average number of attempts for students to pass required licensing exams remained unchanged or improved (decreased number of attempts needed).

8 *p<0.05, **p<0.01, ***p<0. 9 For schools self-identifying as using holistic review, and that track diversity outcomes (N=132) 10 Increased = 1, Decreased = 0, Unchanged = 0 11 A total of 154 (90 percent) of the schools that transitioned to a holistic admission process are evaluating admissions outcomes; within that group, the extent to which schools are measuring specific outcomes varies.