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The Admissions Process: A Snapshot of a Candidate

Following the virtual workshop sessions was the first day of the full hybrid workshop on March 27, 2024, where participants joined both virtually and in person in Washington, D.C. The objective of this workshop

session was to learn from and with colleagues in health professional education about different processes and considerations for admissions. Committee co-chair Christopher Feddock welcomed participants and reminded them of the overall workshop objective, which was “to consider the use of admissions for ensuring a sustainable, high-quality workforce that is adequate in numbers, reflects the population being served, and is equitably distributed.” This first day began with a presentation on admissions trends in the United States, which was followed by presentations about programs seeking to select and grow socially accountable health professionals in Australia. The day ended with an interprofessional table discussion in which a diverse array of stakeholders held small group discussions on issues related to admissions and then reported back to the larger group.

ADMISSIONS TRENDS IN THE HEALTH PROFESSIONS

Amy Addams, the director of student affairs alignment and holistic review at the Association of American Medical Colleges, introduced the first speaker, who presented data on application and admissions trends across the health professions, along with his personal perspectives on what those data mean.

Demographic and Geographic Shifts in the U.S. Applicant Pool for Health Professions Education

George Haddad, founder and chief executive officer of Liaison International, began by saying that the “demographic cliff” may not affect higher education as much as people fear. He explained that the demographic cliff is a decline in the number of high school graduates due to declining birth rates; the total number of high school graduates is projected to peak around 2025 (Figure 3-1). While the decline in the number of young people is real, he said, graduation rates are increasing. The projected decrease in the number of high school graduates will still occur but will be mitigated somewhat by the increase in the percentage of young people who graduate. The impact of the demographic cliff will vary by region and year, Haddad said, with large increases occurring in the South and West around 2025, small decreases in the Northeast and Midwest around 2030, and large decreases in the West, Northeast, and Midwest around 2037 (Figure 3-2). Only 11 states will not see a decline in high school graduates. Because the decline in graduates will occur in the large majority of states, states will not be able to make up for the decline by recruiting from neighboring states, Haddad said. He predicted that state legislators and state systems will make “big efforts” to ensure that they keep as many students as possible in their home state. Haddad emphasized that regardless of the actual numbers of

high school graduates, there are other changes occurring that have affected the traditional approach for marketing educational programs to students. More students are following nonlinear paths, rather than the traditional path of high school to college to the workforce, presenting challenges for educational programs in raising awareness of their programs and recruiting applicants.

The racial and ethnic makeup of high school graduates will shift slightly over the next 10 years, with the percentage of White graduates declining by almost 10 points and small increases in the percentage of graduates from other racial and ethnic groups (Figure 3-3).

Undergraduate and graduate enrollment have decreased since the COVID-19 pandemic, Haddad said, although enrollment numbers increased between fall 2022 and fall 2023, suggesting a recovery. Undergraduate enrollment of individuals 20 and younger has increased each year, but the enrollment of young people ages 25–29 has decreased significantly. Haddad observed that the decline may be due to the fact that the economy is strong and young people are able to get good jobs without further education. There has been significant growth in the enrollment of individuals 17 and younger, he said, which is due to the increase in dual-enrollment programs and direct admissions. These programs recruit students while still in high school, allowing students to simplify the application process and potentially accelerate graduation. A workshop participant said that dual-enrollment programs are sometimes taught by high school teachers who may not have the competency for that level of education. This results in a skills or knowledge gap as these students move forward in their education. Haddad replied that he does not have data on the effectiveness of dual-degree programs, but they are on the rise and will continue to increase. Some institutions that want to hold onto applicants may be willing to compromise and trust that these applicants will make up the knowledge gap through further coursework. Haddad noted that as the number of high school graduates declines, institutions will be competing for a smaller pool of applicants. Programs that work on active and intentional engagement with high school students may be better positioned.

The number of freshmen enrolling in bachelor’s degree programs is on the decline, while the number of freshmen enrolled in associate degree programs or certificate-granting programs is increasing (Figure 3-4). The people seeking certificate degrees, Haddad said, are an important cohort that educators would be wise to keep track of. While a certificate may help an individual get a job initially, the certificate holder may find a more advanced degree is needed to move forward in his or her career. Individuals enrolled in certificate programs are often already in the workforce and either they can afford to take the time to get the certificate or their employer offers the time and money needed for the program as a benefit, Haddad said.

In summary, Haddad said, the “demographic cliff” is still a significant inflection point in traditional higher education. It does not seem likely to be as severe as previously projected, but there will be significant shifts in other areas, including program choice, types of degrees sought, and age of students who are enrolling. Overall enrollments are up in 2023, in both undergraduate and graduate programs; this is primarily a result of a stronger fall 2022 class. Fall 2023 enrollment declined by 3.6 percent compared with fall 2022; this trend suggests slower growth and a longer-term loss of overall enrollments for the next 4 years.

Trends in Health Professions Applications

Graduate education enrollment generally increases during times of economic downturn, Haddad said. If it is difficult to get a job, people go back to school so that they are prepared to get a good job when the economy recovers. This trend held true in health professions education during the COVID-19 pandemic, noted Haddad.

At the beginning of the pandemic, applications to health professional programs went up for the first 6 months. However, Haddad noted that applications dropped after this initial rise, partly due to the dire situation in some hospitals and stories about overworked, burned-out health care providers. Additionally, the trends in the number of applicants and applications varies among health professions. For example, the number of nursing applicants declined from 2019 to 2023, while physician assistant applicants rose over this period. Applicants to public health programs increased significantly in 2020–2021 but returned to pre-pandemic levels by 2023.

Similar to the racial and ethnic trends in general higher education, the percentage of White applicants seeking to enroll in health professions programs declined slightly between 2019 and 2023, while the percentage of other racial and ethnic groups increased. The gender split of applicants has remained fairly steady over time, with the majority of applicants in all health professions being female. Applicant age trends in health professions are similar to general education trends, Haddad said, with the percentages of applicants 25 or older decreasing over time. The percentage of applicants with a Bachelor of Science degree increased over the past 5 years, while applicants with a Bachelor of Arts decreased.

One emerging trend that is critical to keep in mind, Haddad said, is the development of the nonlinear path to the workforce (Figure 3-5). Students may begin taking college classes as early as high school and may move back and forth between different educational programs and the workforce over the course of their careers.

Admissions Technologies and Innovations

Haddad told workshop participants about some of the products that Liaison International has developed to support the admissions process. Liaison offers centralized application services for more than 31 health professions and processes more than 2.5 million applications each year. One tool developed by the company is called IntelligentNames. This program helps to identify “best-aligned adult learners;” that is, adults with a higher propensity to continue their education, which is difficult to assess without a software program. Potential applicants can be filtered by geographic region, educational attainment, and other characteristics. Instead of a school focusing on 3,000 potential applicants, it can use this program to focus on the 200 applicants who are most likely to apply and enroll, Haddad said. Another program is an admissions program that uses artificial intelligence (AI) and machine learning to review applications. By looking at past applications and outcomes, the program can explain the past and predict the future. For example, it can predict how likely an applicant is to matriculate. One limitation of this program, Haddad said, is that models only replicate the past. Data that were not available in the past cannot be used to evaluate applications today. However, another program allows schools to look at applications and rank students using multiple holistic criteria and to weigh these criteria by importance; for example, a school could choose to weight work experience more heavily than academic metrics. Combining the AI model with this holistic admissions program allows schools to select applicants on the basis of both historic data and holistic criteria, Haddad said.

“DARE TO DREAM, PROMISE TO SERVE”

Ricardo Custodio, a professor of health professions at the University of Hawaii, opened his presentation by asking the workshop participants to imagine that they are Little League coaches preparing for their first game. Some coaches train the catchers, others train the pitchers, and others train outfielders. When game day comes, the coaches send the team out together and ask them to play like a championship team. This, said Custodio, is how we have been training health professionals. “Even Little Leaguers know that you have to train and practice together to build a safe, timely, effective, efficient, equitable, and baseball-centered championship team,” he said. With this analogy in mind, Custodio told participants about his experiences in creating an interdisciplinary undergraduate health professions training program. Several years ago, after Custodio had “tried to retire,” he was asked by the University of Hawaii if he wanted to start a health science program. He said that while he had spent his career working as both a health care practitioner and educator, he actually had to Google

“health science.” Health science represents 60 percent of the total U.S. health workforce, he said, and encompasses 85 distinct occupations including audiology, occupational therapy, respiratory therapy, radiography, and pharmacy. Custodio realized that instead of training a handful of clinicians at a time, a health sciences program could train hundreds of individuals for work in good-paying health care careers.

Compared with East Oahu, West Oahu has a higher percentage of Hawaiian Natives and Pacific Islanders, lower incomes and home values, higher rates of poverty and disability, and lower levels of education. To serve this community, Custodio said, the best solution was to “stop recruiting from outside Hawaii and to start actively growing our own from the community.” He noted that many health professions students have grown up with comfortable and stable family lives, private schools, and tutoring. His students, in contrast, are underserved and underrepresented, they are from public schools, they work two jobs, they are single parents, they are disabled, veterans, or recently arrived immigrants. What they have in abundance, however, is “community heart.” These students may struggle in science class, but they “fly in clinical training.” They have been raised to watch over and take care of their family, they have been raised to serve, and they know that they have to serve to survive. Custodio told a story of an experience he had at the local community hospital when he needed continuous bladder irrigation over the course of 4 days. His urologist was a former classmate, and Custodio had done his residency with the urologist’s wife. His hospitalist was a former medical student, and Custodio had worked with the student’s mother at a community health center. Custodio’s son had been trained by his respiratory therapist, and his night nurse was a former pediatric patient. He said there was something “very reassuring and healing” about all the compassion, connections, and support that he felt, and this is what he wanted to replicate in the health sciences program.

The goals of the undergraduate health science program were to create career opportunities, to bridge and establish pathways, and to seek innovation and excellence. Its guiding tenets were that the program must be community-based, must integrate learning with service, and must produce multidisciplinary teams. The program began with six degrees—in health professions, long-term care, respiratory care, community health, health information technology, and Hawaiian and indigenous healing. Custodio focused his remarks on the health professions programs, which has concentrations in physical therapy, occupational therapy, pharmacy, physician assistant, nursing, medical, and general. The curriculum is based on a belief that all health professionals need a foundational understanding of their values, how they communicate, and how they work on a team. In the first month of the program, all students begin by taking two classes: Survey of Health

Professions and Introduction to Clinical Skills and Patient Care. In Survey of Health Professions, students are exposed to a wide variety of health professions through a multidisciplinary group of expert guest speakers. Custodio said he asks the speakers to talk not only about their job but also about the journey they took to get to where they are. For most students, this part has the greatest impact. Speakers have included a family practitioner who grew up in a refugee camp, a mental health expert who had to hustle pool to survive, a dietitian who was on the team that won the Molokai-to-Oahu canoe race twice, and former students, one of whom was a physician who became the governor of Hawaii. For students in this program, “exposure changes trajectory.” The stories they hear, Custodio said, unlock their minds to see other possibilities. A participant asked how the program balances the need for students to specialize with the flexibility of exploring multiple professions. He said that students choose a specialty early on in the process, but their experiences as part of interprofessional teams with other health professions students help them either solidify their choice or decide to explore another path.

The second required foundational class, Introduction to Clinical Skills and Patient Care, is designed to help students figure out if they like performing clinical skills and being in patient care settings. Custodio commented on his colleagues in medical school, saying they went all the way through school before realizing they really did not like touching patients. The class includes sections for hands-on clinical skills, CPR certification, mental health first aid, threat assessment, school and clinical site visits, and clinical cases. A workshop participant noted that some health professions programs don’t offer opportunities like this until several years in and said that waiting to introduce these skills can result in students leaving the program because they aren’t engaged. Custodio replied that through early introduction to hands-on clinical skills, a few students decide that the career is not a good fit and leave; he said he is “really happy” when students figure this out early. Custodio described how, at the end of the semester, students participate in a culturally appropriate “ho’ike”—a final presentation to display what they learned over the semester. All classes participate together, a potluck is served, and family, children, and pets are invited to join the celebration.

This program builds a multidisciplinary team by instilling purpose, Custodio remarked. Pre-health professionals from multiple disciplines can train together, get to know one another, learn to communicate, and work as a team. He finished by saying, this type of training needs to begin long before health professionals enter the workplace.

GROWING SOCIALLY ACCOUNTABLE GRADUATES: FROM PRE-ADMISSIONS THROUGH PRACTICE OUTCOMES

Where health professions students are trained is a significant influence on where they ultimately work, said Zohray Talib, the executive vice dean for education at the California University of Science and Medicine. In opening the session, Talib shared an example of a medical school in rural sub-Saharan Africa that implemented holistic admissions. Rather than simply accepting the top students who applied, the school took time to interview students and figure out “who really wants to come and stay here.” The result of this process was a class made up of a different kind of medical student. While some students did need a bridge to help them succeed in medical school, this holistic review process with a lengthy interview “flipped the narrative” about how admissions can influence the future health workforce in a community. Talib introduced the speaker for this session of the workshop, who shared her experiences with growing fit-for-purpose health professional graduates in Australia.

Australia is a country of roughly 26 million people, but the vast majority of people live in the southeast corner, began Sarah Larkins of Australia’s James Cook University (JCU). Northern Australia is a “huge land mass,” she continued, with 1 million people; its largest town has a population of only around 200,000. In this context of rural and remote Australia, JCU was established as a health professional school. She underscored one of the biggest challenges in Australian health care, which is the maldistribution of the health workforce. This maldistribution is seen both in terms of geographic distribution of workers as well as in terms of a surplus of specialists and a lack of generalists. JCU is Australia’s most successful university in producing health professionals who go on to work in regional and remote communities, Larkins said. Across Australia, 20 percent of health professionals who completed the Universities Australia Graduate Outcome Survey and who work in outer regional, rural, and remote locations are JCU graduates. Larkins reported that 70 percent of those from outer regional locations stayed in outer regional and 78 percent of students from remote locations stayed in outer regional or remote areas. Among JCU medical school graduates, 66 percent stay in the region after graduating, and just under half pursue careers in general practice.

JCU’s approach to recruiting and training students in rural and remote areas is driven by a desire to address the needs of the population, Larkins said. Meeting the needs of the population requires education and training in underserved areas, creating fit-for-purpose health professional graduates, and building partnerships between the health sector and communities. When considering how to accomplish these three aims, it is important to think about the appropriate role of health professional educational

institutions. “Is the role of a school just to train doctors and other health professionals to a set of professional standards?” Larkins asked. Increasingly, there is a recognition among health professionals and communities that the role of a school is “considerably more than this.” To truly make progress on equity and access to health services, schools would need to partner with the health sector, with policy makers, and with communities themselves. Health professional educators have an obligation to be “trans-formative agents” in training young doctors and other health professionals in the knowledge, skills, and attitudes necessary to address the priority health needs of underserved populations, Larkins said. The question, therefore, is whether a school is teaching the right people the right things at the right time in the right places.

Who the “right” people are depends on the mission of the school. What we do know, Larkins said, is that representation is really important. People do best when they see themselves reflected in their chosen health profession and researchers. In the context of Aboriginal health work, process and relationality are “incredibly important.” To find the “right” people, a school would have to start by defining its desired outcomes, then select for those outcomes. Simply “turning on the tap” of the rural pipeline is not enough to ensure that people from underserved communities will apply to a program. Instead, there is a need for appropriate pathways and drivers toward generalism, including in post-graduate programs. Traditionally, health professional training has recruited from cities, enrolled the children of city elites, and emphasized specialist training and work in large acute-care settings. Not surprisingly, this approach has mostly turned out urban medical specialists, Larkins said. If health professional training programs instead recruited from areas of need, enrolled a diverse group of learners, and emphasized generalist training in community- and team-oriented settings, the health professional workforce coming out of the program would likely be quite different from the traditional approach.

Larkins turned to describing the Training for Health Equity Network (THEnet), in which JCU is a partner. THEnet is a community of practice of 12 health professional schools located all around the world. These partner schools have a social accountability mission, and a key strategy is to recruit learners from underserved communities so they will return and address local health priorities. One of the first activities of THEnet was to develop and publish a common evaluation framework for schools to use to critically reflect and self-assess their progress toward social accountability. The framework has four main components: (1) understanding the population being served and their needs; (2) understanding how the school works; (3) understanding what the school does; and (4) assessing what difference the school makes. Larkins and her colleagues undertook a research project to evaluate the impact of THEnet schools by studying how selection strategies

influenced representation of underserved populations and students’ intention to practice. The researchers found that students in THEnet schools were far more likely to originate from rural backgrounds. Looking at entry and exit questionnaires, the researchers found that intention to practice in family medicine or general practice was nearly twice as high among exiting students as among entering students, while intention to practice surgery was nearly three times as high among those entering than among those exiting. Those exiting also reported a far higher intention to stay in the student’s home country than to practice abroad, compared with those entering. This research involved around 6,000 students, Larkins said, and it is particularly important for schools in low- and middle-income countries. Larkins told participants about a related study that found the practice locations of graduates of THEnet schools in the Philippines were far more widely distributed across the country than those from a traditional medical school.

The health professional programs at JCU are growing in popularity, Larkins said. There are approximately 4,000 applications for 200 spots in the medical school, with much of the growth coming from metropolitan areas. JCU has adjusted its selection process to ensure that the majority of offers continue to go to students from rural, remote, and outer regional locations, Larkins said, adding that the ratio has remained at around 2:1 for over 10 years. It is important for health educators to “start with the end in mind” in designing recruitment, selection, and training processes for health professional programs. There is strong evidence about the importance of training a fit-for purpose workforce, and the workforce begins as a group of students. Larkins underscored how selection processes could address diversity and equity as well as academic success and competence, adding that these are not mutually exclusive criteria. A workshop participant asked Larkins how schools in the United States can address diversity and equity when there are restrictions on affirmative action. Larkins replied by suggesting some strategies that could work, such as using “rurality” as a consideration. Talib agreed that geographic preferences can be used to accomplish diversity and equity. For example, the California University of Science and Medicine uses geographic preferences to ensure that around one-third of the class comes from the Inland Empire, an underserved area with severe health workforce shortages.

Larkins also commented that educators can hold themselves responsible for the health system and workforce outcomes from their graduates; “the job of an educator doesn’t stop when the student walks out the door,” she said. In closing, Larkins encouraged the workshop participants to reflect on what they could do with their own institutions’ selection and admissions processes to ensure recruitment and training of a diverse and representative cohort of students and the increased likelihood of producing fit-for-purpose health professional graduates to meet the needs of the population.

INTERPROFESSIONAL TABLE DISCUSSION

In this session of the workshop, participants broke into small groups to discuss how they could collaborate to help potential applicants better understand and navigate the diverse professional pathways that exist in the health professions. After the table discussions, representatives from each group gave a brief summary of that group’s conversation. All of the respondents were from the United States.

Spector began the report-backs by asking another member of her group, who is in college, to describe her experience in high school. The young workshop participant said she attended a half-day exposure program for dental assistants during high school. This program allowed her and her classmates to get clinical experience and learn the basics of dentistry. She attended community college before transferring to a 4-year university and is now pursuing her bachelor’s degree in biology and plans to apply to dental school. Spector added that her group also discussed the importance of mentoring and suggested that retirees could be excellent mentors.

Merrick then reported that his group discussed the importance of identifying skills needed for a particular field or profession and communicating those to applicants during the application process. This will help applicants honestly assess their potential for success in the program and whether the field is a good match. If an application “doesn’t result in acceptance and enrollment,” Merrick said, the Centralized Application Service allows applicants to transfer all of the materials to a different field or program. Merrick noted that he has been doing admissions for 25 years and only learned about this innovation during the workshop.

Elchert reported next that his group focused on the words “knowledge” and “navigate.” There is a desire for young learners to have “quite a bit” of exposure to health sciences, particularly through experiential learning. Starting early in a developmentally appropriate way makes it possible for young people to build a sense of self-efficacy and to be able to visualize themselves in a particular profession. Also noted in their discussions, Elchert said, was how the health sciences could broaden potential areas for recruitment. Currently, there is a singular focus on a matriculation process that comes out of high school. In addition to this pathway, Elchert suggested that health sciences could look to “capturing” individuals from the broader STEM workforce who might not be traditionally trained as health care professionals but who could offer relevant skills with support from the education and training community.

Mark Colip, president of the Association of Schools and Colleges of Optometry, said that his group agreed with others about the importance of early exposure to the professional pathways within health professions. Many prospective students only have exposure and awareness of a few

professions, such as medical doctors, nurses, and dentists. Exposure is key to helping them understand that there are other professions, he noted. By the time a learner gets to college, however, it may be too late to create a strong drive and interest in other professions. Exposure needs to begin as early as middle school or even elementary school, he added. To accomplish this, partnerships among providers, educators, and legislators would be necessary, along with an infrastructure that could identify students who start in one pathway but might be a better fit in another pathway. Colip reflected on how some health professions have far more demand than capacity, while others have more capacity than demand. A barrier to helping students shift from one pathway to another is a lack of common prerequisite courses or joint training, he said. In addition, students also face barriers that prevent them from exploring all options within the health professions. One major barrier for students from underserved communities, he said, is a lack of personal belief in their ability to escape poverty. Early exposure to the health professions and creating an environment for success is one way his group discussed for overcoming the challenge. This could include sleepover and day camps, programs in elementary schools, and mentoring with current students, he suggested.

Addams said her group also focused on the importance of early exposure, through hands-on experiences and demystification of the various health professions. She agreed with others that while most young learners are familiar with the professions of doctor or nurse, they may not know the full scope of what these jobs entail. In addition to early exposure for students, Addams said, it is important to think about how people in different health professions could be supported in moving up in their own field or to a new health profession through additional education or training. Addams commented that her group got “aspirational” in their thinking about how the system could be transformed to better support students exploring different professions. For example, health professions graduate programs could be undifferentiated in the first year; students would all learn together and begin to identify which professional path each may want to take. Another way to support exploration, Addams said, would be by harmonizing prerequisites across health professions. Currently, an applicant may have the opportunity to apply to a different profession but be unable to do so because the prerequisites differ so much across professions.

Cahn gave the final report-back on his in-person group’s conversation, saying that they discussed themes that were similar to those covered by other groups, specifically about early exposure and collaboration among programs to identify students who may be a better fit elsewhere. Cahn underscored the many roles within the health care system that aren’t traditional health professions, such as coders or care coordinators. These are roles that may be attractive to people who are not interested in direct

patient care. At MGH Institute of Health Professions, the health sciences learning community provides a way for all health professional students to socialize and to get a better understanding of the common path they are on, he said.

Lastly, Francis-Johnson reported on the discussion held by the virtual group. Like their in-person counterparts, the online participants emphasized early exposure and the importance of “planting that seed early” so learners could see themselves in a health professional role. The group also talked about developing activities where people from different professions can collaborate to help learners explore different career paths, she said.