Taylor Walker, a 25-year-old pregnant woman, lived in a town of under 500 people in rural Nebraska. In 2019, she told NPR that after experiencing pregnancy pains, she endured a four-hour round-trip journey to see her physician only to discover her regular doctor was unavailable. In the end, she was forced to repeat this arduous trek multiple times just to receive necessary care. For Taylor and countless Americans, this is not just an inconvenience but a dangerous reality. Their struggle reflects a systemic failure affecting the millions of Americans who live in medically underserved areas. How did we end up with a country where access to physicians depends so heavily on where you live?
The answer is, in part, medical schools. By rejecting most applicants, these institutions wield enormous power over the composition of the physician workforce. Yet there is no mechanism to align institutional admissions with public health needs. The result is that privilege drives acceptance: Half of all medical students come from the wealthiest 20 percent of families and from just fifty elite feeder colleges. This inequity in admissions has contributed to doctor shortages affecting one-fifth of Americans, resulting in significant health disparities between communities despite various incentive programs designed to encourage physicians to practice in high-need areas. It’s time for a truly equitable approach to medical school admissions.
I propose requiring medical schools to create balanced classes where no more than 40 percent of students come from any single socioeconomic quintile, with at least 10 percent coming from each. To approximate socioeconomic status, we need to expand how the AAMC classifies applicants’ backgrounds. A new scoring system could assess multiple domains, including family income, parental education and occupation, first-generation college status, and geographic origins, particularly noting if applicants grew up in physician shortage areas. A “socioeconomic score” could be generated from this information. This process would serve two critical purposes: First, it would enhance educational equity by accounting for barriers disadvantaged students face in accessing medical education. Second, it would recruit talented individuals who are more likely to serve high-need areas. Socioeconomic prioritization would substantially increase recruitment of physicians from rural communities, lower-income families, and underrepresented backgrounds.
Improved representation across the socioeconomic spectrum matters because physicians from disadvantaged backgrounds are more likely to practice in communities with the greatest needs. Put simply, physicians who grew up in wealthy, well-resourced communities rarely choose to practice in underserved areas, while those with disadvantaged backgrounds are more likely to feel a connection that draws them to return to similar communities. Once in these communities, physicians improve health outcomes, provide more culturally appropriate care, and reduce health care costs through better preventive services.
This ambitious redesign of medical school admissions would require careful implementation. We should begin with randomized controlled trials of different quota systems, tracking where graduates practice and measuring changes in community health outcomes to assess effectiveness. Long-term success would also depend on oversight from an independent group of public health experts, medical school, and underserved community representatives.
Some doctors and patients might worry that quotas would reduce the quality of health care, but evidence does not support this concern. In fact, too many qualified but disadvantaged students are left out of the medical education pipeline. Research has demonstrated that medical students from lower socioeconomic backgrounds perform just as well as wealthier classmates as measured by graduation rates. Successful precedents for quotas already exist: Dutch medical schools previously used a partial lottery system, which yielded graduation rates nearly identical to ours, while India’s quota system is far more aggressive than this proposition and has yielded reassuring academic outcomes. Furthermore, U.S. military service academies already use geographic quotas. Better socioeconomic representation in medical school admissions offers a practical middle ground between two alternatives: service requirements for high-need areas that fail to train physicians who actually want to practice in these communities, and lottery-based admissions that would maximize representation but might exclude exceptional candidates who could advance the field of medicine.
Socioeconomic quotas will ensure that doctors better reflect the diversity of Americans. For patients like Taylor Walker, this change could mean the difference between an exhausting four-hour drive and local care from a physician who comes from and therefore understands her community. Americans will no longer need to “ride out illnesses” until they become emergencies. Instead, they will have physicians eager to serve the neediest patients. A health care system where doctors represent and understand the full diversity of American communities would become a higher-quality, more equitable system.
Jacob Murphy is a medical student.
