The black box of medical admissions

The issue of systemic racism and privilege is one that permeates the political, societal, and cultural zeitgeist of our current times. From Canada to the United States and the UK, movements like Black Lives Matter and recent changes to immigration policies have opened up increasing conversations around adversity, civil rights, immigration reform, wealth disparities and class differences. When it comes to higher education, for example during the medical admissions process, these same political and societal issues play out in the educational arena. 

In the United States, the College Board, an organization that represents over 6,000 schools, colleges, and administers standardized tests and curricula, most notably the PSAT and SAT exams, took a controversial decision to incorporate a measurement of “adversity” into the admissions process known as Landscape.1 Previously known as the “Adversity Index”, Landscape provides colleges with data points from government sources that have been identified as affecting education. Factors such as whether applicants live in a rural or urban location, senior classroom sizes as well as participation and performance in AP classes are considered. Information about family income, parental education levels and neighbourhood crime rates are also assessed.2 The College Board claims that Landscape is not intended for colleges to use the information in deciding which students to admit or not, but rather will allow for a more comprehensive and fair look into a student’s life. 

The current admissions process functions very much like a blackbox; little is publicly understood about exactly what it takes for a student to be admitted into their school of choice and how the admissions process works. Initiatives like Landscape further highlight the fact that there is an overwhelming need in higher education to “level the playing field” between students who have a certain level of privilege over others. College admissions are uniquely difficult to navigate for low income students when it comes to issues related to adversity and wealth disparity. Students from lower income families have limited access to tutors, test prep courses and are often employed in addition to being full time students. The role that wealth plays in the educational system and admissions process was brought to the forefront of mainstream media in March 2019 with the “Varsity Blues” scandal, a term coined to describe the actions of affluent and celebrity parents bribing schools into admitting their children. While this is a drastic example of the extent to which wealthy families are capable of gaming the admissions process, wealth disparities can lead to biases against low income students in other innocuous ways. For example, colleges are more likely to admit students who are able to pay for tuition and other expenses over a four year period without requiring financial aid3. This puts low income students, who may be otherwise well qualified to be accepted into their programs of choice, at a disadvantage in comparison to their wealthier counterparts. 

There are many questions that arise when it comes to levelling the playing field and making the admissions process equitable for all students. While it is difficult to quantify adversity with a single measurement tool, schools can widen access to more students during their admissions process by incorporating professionalism assessment tools to allow for a more holistic evaluation of an applicant. These tools would promote student diversity and broaden the representation of all demographic groups in medical schools and other institutions of higher learning4. Traditional cognitive assessments such as the MCAT, SAT and GPAs have shown lower performance in students who are underrepresented in medicine (UIM). In a 2019 study, Juster et al proposed the incorporation of the SJT test, Casper, to counteract what they describe as the “diversity validity dilemma” which describes the tradeoff between valid predictors of performance and minimizing adverse impact on students who are UIM for a variety of socioeconomic factors. The authors suggest that a higher weighting of Casper scores may help in increasing gender, racial and ethnic diversity in the interview pool5. In a study at New York Medical College School of Medicine, traditional cognitive assessment measures showed significant differences along socioeconomic status, gender, race and ethnicity variables. However, these differences in performance for UIM students were minimized or reversed when used in conjunction with assessments of non academic competency such as Casper and the MMI. 

The inclusion of professionalism assessment tools can’t altogether eliminate racial and socioeconomic variables that affect access to higher education. However, the inclusion of SJTs and improvements to their validity can widen access to education for a larger demographic of students, which in turn can aim to increase the diversity of future physicians and address the needs of a diverse population. 


  1. College Board Announces Improved Admissions Resource. (2019, August 27). Retrieved from:
  2. Frequently Asked Questions: Environmental Context Dashboard. (2019). Retrieved from:
  3. Lieber, Ron. (2019, March 15). Another Admissions Advantage for the Affluent: Just Pay Full Price. Retrieved from:
  4. Lievens, F., Patterson, F., Corstjens, J., Martin, S., & Nicholson, S. (2016). Widening access in selection using situational judgement tests: evidence from the UKCATMedical Education50(6), 624–636. doi: 10.1111/medu.13060. 
  5. Juster, Fern R. MD; Baum, Robin Camhi MS; Zou, Christopher PhD; Risucci, Don PhD; Ly, Anhphan; Reiter, Harold MD; Miller, D. Douglas MD; Dore, Kelly L. PhD “Addressing the Diversity–Validity Dilemma Using Situational Judgment Tests.” Academic Medicine, vol. 94, no. 8, 2019, pp. 1197–1203., doi:10.1097/acm.0000000000002769. 

By: Nimo Jama, Research Assistant at Acuity Insights