Why Legacy Admissions Has No Place in 21st-Century Medical Education


Rebecca L Volpe PhD and Kimberly R Myers, MA, PhD

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Legacy admissions, which occur when an educational institution gives preference to certain applicants based on their familial relationship to alumni of the school, are common. A 2018 survey by Inside Higher Ed found that, on the undergraduate level, 42% of private education institutions and 6% of public education institutions report that legacy is considered as a factor in admissions. This practice has long been identified as a target for reform. Some universities have announced bans on legacy admissions—Texas A&M in 2004 and Johns Hopkins in 2020, for example. In May 2021, the state of Colorado banned legacy admissions for all public baccalaureate and graduate institutions.

The issue of legacy admissions is relevant to medical education. Indeed, legacy considerations in medical education date back to the original Hippocratic Oath (circa 400 BC), which begins by asking the physician to swear that he [sic] will privilege his own and his mentor’s children with regard to educating them in the art of medicine:

To hold him who taught me this art equally dear to me as my parents[ . . .], to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.

Although modern versions of the oath do not contain this statement, medical historians have speculated that the centuries-long use of the original oath may have constrained access to early medical education by requiring strict loyalty to families of physicians and explicitly denying access to outsiders.    

No empirical data exists about the current prevalence of legacy policies or practices in medical school, and we found only one peer-reviewed article that explored the issue from a theoretical perspective. However, anecdotal evidence suggests that legacy practices in medical school admissions are common, if also vaguely troublesome. For example, several Colleges of Medicine advertise special programs (here and here) or guaranteed interviews for legacy students, while simultaneously noting that legacy status does not factor into the likelihood for acceptance into the medical school. This paradox exemplifies the problem: a complex push-pull between the desire to preserve medicine’s honorable traditions while at the same time fulfilling contemporary commitments to equity and fairness.

We currently serve on separate medical admissions subcommittees for our institution. A process was long been in place here to identify and vet candidates whose parents were on faculty or who had other personal connections to the organization; we refer to these applicants as ‘legacy’ applicants. The process of identifying legacy applicants originally emerged as an attempt to prevent conflicts of interest for interviewers who might know their colleagues’ children. Additional reasons for such a process may also seem compelling. Members of admissions committees may believe that legacy students are more likely to accept the school’s offer of admission because of personal connections to the school or that legacy students may be more prepared for the rigors of medical training because of “insider knowledge,” including an understanding of the hidden curriculum. Despite their face-validity, however, these arguments in support of legacy admissions practices are flawed. Our own admissions data indicates that legacy students are no more likely to accept an offer to matriculate than non-legacy students. And recent research demonstrates that despite their high rates of application to medical school, the children of physicians are no more likely to succeed in medical school than their non-legacy counterparts.

Other considerations may also play into some legacy policies. Medical schools—and their students and faculty—benefit from financial gifts by wealthy alumni. Admissions leaders may experience pressure from administrators, alumni and/or development offices, and even local and state politicians who view legacy admissions as a “courtesy” to donors who fund important initiatives.

These concerns notwithstanding, legacy admissions are ethically problematic. Not only do they confer an unearned benefit on the student; they also undermine the widely agreed upon goal of getting more diverse applicants through our doors and into practice. At institutions where most of the graduates are White, considering legacy status essentially assures a continued struggle to improve the percentage of underrepresented in medicine (UiM) students who matriculate. What’s more, legacy is not just a problem for rural, historically White medical schools: while the U.S. general population is increasingly diverse, with about 30% of Americans identifying as minorities, fewer than 15% of matriculants to medical school identify as minorities. Deeply ingrained legacy admissions processes exacerbate these problems of inequity.

Institutions operationalize legacy processes differently. In our institution, candidates were historically asked to indicate on the application form whether they have personal connections to the medical center. Until very recently, those who answered yes were sent to a separate admissions committee where a Yes/No vote was taken. If a majority of the committee voted Yes, the candidate was admitted. By contrast, non-legacy candidates were ranked on a point scale and were thereby in competition with one another for admissions slots that are so scarce that often a score of 4.5/5, for example, is insufficient for admission. These divergent processes worked to unfairly favor the admission of legacy students.

A recent case illustrates this point: In an admissions meeting of non-legacy candidates, after each applicant was presented and discussed and individual committee members’ numerical ratings were tallied, two UiM candidates’ mean scores were 4.9 (out of 5).  Because of the fierce competition at this late stage of the admissions cycle, only a very few of the 30+ candidates under review that day would advance, and these decisions were made purely on math. That is, after scores were calculated, no further discussion occurred. Because other candidates’ mean scores were 5, neither of the two excellent UiM candidates made the cut—this despite the committee’s avowed and strong commitment to increasing diversity in our student population.

The following day, a non-UiM legacy candidate was presented at the separate committee that reviews legacy applicants. The candidates’ scores were strong as was the application packet. Comments (and, consequently, numerical ratings) from two faculty who interviewed the candidate, however, indicated that the candidate seemed ambivalent about coming to our institution. Highly valuing the observations of our faculty interviewers, the committee discussed the implications of this applicant’s relative disinterest. Nevertheless, when the committees’ yes/no vote occurred, the candidate earned an offer based on the strength of the application, which was in line with—but not superior to—that of the UiM applicants who had been rejected just the day before.

This experience led to an examination of and change in our institution’s policies and procedures. All candidates, regardless of legacy status, are now vetted in the usual committees alongside other applicants. We are proud that this new process reflects our commitment to fairness and to diversifying medical training and practice, not only in terms of race and ethnicity but also in terms of values and experiences (e.g., first-generation college students). As we deliberate on who has the potential to flourish in medical training and long-term practice, one consideration in our holistic assessment is “distance traveled”—that is, the degree to which the student has demonstrated resilience and perseverance in the face of obstacles. 

Legacy admissions are ethically problematic because they expand the advantages of an already-privileged group, and they undermine the goal of welcoming more diverse perspectives into our profession, a critical objective as the general population itself becomes increasingly diverse.  Eliminating legacy policies is a simple step in the right direction. Close examination of such policies on the local and national levels is long overdue. We call on individuals who are involved in medical school admissions to learn about their own schools’ legacy practices, and on medical education researchers to define the nature and scope of legacy admissions in undergraduate medical education, so that empirical data may support future decision-making in this area. The nepotism of the past has no place in the present. 

Acknowledgments: The authors wish to thank the College of Medicine leadership for their support in the publication of this blog.

Rebecca L. Volpe PhD is an Associate Professor with the Department of Humanities, Penn State College of Medicine.

Kimberly R. Myers, MA, PhD is a Professor with the Departments of Humanities and Medicine, Penn State College of Medicine.

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