The relationship between required physician letters of recommendation and decreasing diversity in osteopathic medical school admissions.

Context: Some racial and ethnic groups are underrepresented in the medical field because they face unique barriers to admission to medical school. One admission requirement that can present a barrier for applicants is the physician letter of recommendation (PLOR). Undergraduate students report confusion with the application process and lack of mentorship to be two of their biggest challenges to becoming a doctor. It is especially challenging to those who already have limited access to practicing physicians. Therefore, we hypothesized that in the presence of a PLOR requirement, the diversity of students who apply and matriculate into medical school will be decreased.

Objectives: This study aims to determine if a relationship exists between a PLOR requirement for the medical school application and the proportion of underrepresented in medicine (URM) students applying and matriculating to that school.

Methods: A retrospective study was conducted utilizing data published by the American Association of Colleges of Osteopathic Medicine Application Services (AACOMAS) on the race and ethnicity of applicants and matriculants to osteopathic medical schools during the years 2009-2019. In total, 35 osteopathic schools with 44 campuses were included in the study. Schools were grouped based on whether they required a PLOR. For each group of schools, descriptive statistics were performed for the following variables: number of total applicants, class size, application rate per ethnicity, matriculation rate per ethnicity, number of applicants per ethnicity, number of matriculants per ethnicity, and percentage of student body per ethnicity. The Wilcoxon rank-sum test was utilized to detect differences between the two groups. Statistical significance was assessed at the α=0.05 level.

Results: Schools that required a PLOR showed decreases in the number of applicants across all races and ethnicities. Black students showed the greatest difference between groups and were the only ethnicity to show significant reductions across all outcomes in the presence of a PLOR requirement. On average, schools that required a PLOR have 37.3% (185 vs. 295; p<0.0001) fewer Black applicants and 51.2% (4 vs. 8.2; p<0.0001) fewer Black matriculants.

Conclusions: This study strongly suggests a relationship between requiring a PLOR's and decreasing racial and ethnic diversity in medical school matriculants, specifically the Black applicants. Based on this result, it is recommended that the requirement of a PLOR be discontinued for osteopathic medical schools.