—The Editors

Medical school admissions committees now face significant social problems as they try to steer a path between egalitarianism and elitism. Thus, the results of medical school admissions must be viewed as much in terms of the good of society as of the private interests of schools and their students.

For about a decade I have been at work on a history of premedical education in the United States [1, 2]. In the course of this study, I have also tried to understand the changes that have occurred in the admissions process since the founding of our earliest medical schools in the 1760s, when we were still under British rule. The process of getting into medical school has changed markedly during these two centuries. In the last 60 years, places in medical schools have become scarce resources, and competition for them has become intense.

By the 1920s, medical school admissions became increasingly selective. Schools had more applicants than they could find places for in their classrooms or hospital wards. By 1925, some of the leading medical schools had 5 to 10 times as many applicants as they could accept. Others, however, still did not have enough, and the estimate is that, collectively, medical schools that year had as many as 1500 unfilled places [3]. This situation soon changed, and in the 1930s, with economic factors playing an important role, restrictive practices began in earnest. These practices were to limit the overall number of physicians in society, but they also singled out certain applicants, such as women, Jews, and blacks, in a manner that turned medical school admissions into a society-wide concern. Thus, although the admission of future doctors may seem a problem for our profession alone, the process can serve as a window that sheds light on many broader social issues of the last 75 years.

To set the changing admissions practices in a historical context, I describe the application processes of three 20th-century physicians: George Minot, who went to medical school early in the century; Margaret Morgan, who, after overcoming many obstacles, matriculated in the 1930s; and Allan Bakke, whose troubled but highly significant path to medical school furnishes an example from our own time. These extremely different admissions experiences illustrate many points, the most important of which is that the admissions process has never been static, and even the individual examples I provide do not truly capture the richness of the experiences of different students in different schools at the same or different times.

George Minot at Harvard

George Minot, born to a prominent Boston medical family in 1885, had a relatively untroubled path to medical school. The only problem he had to overcome was the final decision to follow in his father's footsteps and pursue the study of medicine. His admissions story is typical for his time and for his social class, although in the years before the World War any student who could pay the matriculation fees could enroll in a school of medicine.

In September 1904, George Minot, almost 19 years old, began his college studies at Harvard. As his cousin, fellow student, and biographer Dr. Francis Rackemann noted, "Our relatives and friends had gone there; it was the logical and natural thing to do after graduation from school. No alternative was suggested or considered" [4]. The boys did have to endure the Harvard entrance examinations, which Rackemann recalled as "a grueling experience".

As Rackemann described it, "Under the elective system, the choice of courses required careful thought. With his father a doctor, his cousin Charles Minot a professor in the Medical School, and other relatives on both sides interested in medicine, George knew that his blood had a medical tinge to it" [4]. Thus, although a career in medicine seems to have been inevitable for Minot, he appeared to entertain some doubts at the end of his college career.

Although there was considerable criticism of the great freedom of elective choice in the undergraduate education available at Harvard during Charles William Eliot's long presidency from 1869 to 1909, Minot's choice of courses included a broad array of the sciences, some of the social sciences such as economics, and several courses in the humanities. It was a good liberal arts education. His senior thesis was about the new Social Work Department created by Dr. Richard C. Cabot and Miss Ida B. Cannon at the Massachusetts General Hospital.

As a student, George really found himself in his senior year when his grades were all A's. Because of this strong finish to his 4-year Harvard education, Minot graduated cum laude in 1908. Years later, Rackemann nicely captured the essence of their collegiate experience: "In his four years at Harvard College, George Minot's personality had developed enormously. He had caught on to the value of knowledge and the methods of obtaining it. He not only could absorb, but he could classify and digest the material that was presented; it meant something to him. Meantime, he had become less shy, much more approachable and ready to meet people on a common ground" [4]. Minot had matured, one of the reasons we still believe that a college education is good preparation for the study of medicine.

Rackemann also recalled that the two of them, both the sons of doctors, often talked about medicine, but neither was entirely sure if he wanted to go to medical school. Because both had Harvard degrees and better-than-average records, admission, they knew, posed no problem: "If we wanted to go to the Harvard Medical School, all we had to do was to walk in and register. That last, however, was such a vital step that it was hard to be sure that we wanted to take it. It is interesting that in our last year in Harvard College, Cousin Charles Minot had hinted to our families that microscopes would make very acceptable graduation presents for us" [4].

The two cousins felt little urgency to make a decision, and so they separated for the summer of 1908, with George sailing for Europe. When he returned at the end of the summer, he and his cousin talked more about going to the medical school. In their world there was only one medical school to be considered. So they decided to go to medical school on a Monday in late September. On that day, they ran some errands and watched football practice; the next day, they picked up their college credentials in Cambridge and on Thursday, 1 October 1908, were among the 65 men who began their medical studies in the Harvard Medical School Class of 1912. A decade after their graduation, the discovery of insulin saved George Minot's life, and he went on to an illustrious medical career that included the Nobel Prize in 1934 for work on the treatment of pernicious anemia with liver [5].

Margaret Morgan in New York

Eighteen-year-old Margaret Morgan arrived on the Cornell campus in Ithaca, New York, in the fall of 1932. Determined eventually to study medicine, she began the long road to a medical career with a double handicap. This young freshman student was not only a woman, she was also black, the only black undergraduate student in the College of Arts and Sciences that year. In the memoir of the future Dr. Margaret Morgan Lawrence, lovingly told by her daughter, Sara Lawrence Lightfoot [6], we learn much of the heartbreak and hard work that was a part of the road to medical school in the 1930s for minority students. Margaret Morgan's experiences may not be those of the typical applicants of the 1930s, but they offer insight into what it took to get into medical school and, specifically, what was required for a black woman in a white man's world.

Margaret Morgan left her native Mississippi at age 14 to attend high school in New York. After living in Harlem for 4 years, the excitement of a large university campus like Cornell's was partly blunted by the fact she was not only the lone black student that fall but that, as a black, she could not expect to live in the college dormitories.

Margaret arrived in Ithaca with 9 dollars in her purse and a scholarship for her tuition costs, but she still needed to work for her room and board. She was forced to work as a maid, in uniform, when she was not attending classes. Only in her senior year was she able to live free of such chores. Her grades were strong, and she threw herself with special vigor into the premedical science courses. She fully expected to gain admission to the medical school of Cornell University.

Despite a fine record that improved as she neared graduation in 1936 and high scores on the Moss Test, the 1930s forerunner of the Medical College Admissions Test, her dream of gaining admission to the Cornell Medical School was dashed on the rocks of the racism so typical of the time. The dean of the medical school told her that, after due deliberation, the Admissions Committee was forced to deny her a place because a quarter of a century earlier Cornell had admitted a black student who unfortunately "did not work out". The student contracted tuberculosis, and apparently, 25 years later, in 1936, the school was not willing to be so venturesome again.

Help from a sympathetic New York friend who had influence at Columbia resulted in an interview at that medical school, although it was already late spring. Margaret Morgan was admitted to the College of Physicians and Surgeons for the fall of 1936, 1 of only 10 women in a class of 104 [7].

To put her application in a wider context, in the United States in 1936, 12 192 students filed over 35 000 applications. Of those who applied, 6465 (53%) were accepted to at least one medical school, and 5727 (47%) were rejected entirely [7]. The number of applications in 1936 was down slightly from the previous few years. Whether this small decline was owing to a slightly improved business or economic climate is hard to say. Applications were highest when jobs were scarcest during the depths of the depression in the early 1930s.

Margaret Morgan was among 659 women who applied to medical school in 1936, an increase from 3 years before when only 507 applied. Of the 659 female applicants, 373 were accepted that year. Admissions at Columbia reflected the national trend. Forty-five women applied there in 1933, but in Morgan's year the number rose to 75, of whom 12 were accepted, although apparently only 10 women actually enrolled [7].

Margaret Morgan was only the third black student to attend the medical school at Columbia. Predictably, the reason so often given by the schools for excluding both blacks and Jews—that housestaff positions could not be found for them—came true in Margaret's case. She wanted an internship at Babies Hospital but was told that the female interns had to stay in the Nurse's Residence and that the Superintendent of Nurses refused to have a black woman housed there; so, she interned at Harlem Hospital. Despite the obstacles in her path, Margaret Morgan became a distinguished and innovative pediatric psychiatrist. Her premedical education was better than that of most of the students of her time, and her admissions story was probably more typical than we would like to admit.

Allan Bakke at the University of California

Much has been written about the case of Allan Bakke, an engineer in his early 30s whose quest to gain admission to medical school became a landmark in legal and social history in the mid-1970s [8-11]. Bakke's story, his great passion to become a doctor, and the light that his medical school applications sheds on the admissions process of the time demand that we include him as one of the important figures in the history of restricted medical school admissions.

The sprawling Davis campus of the University of California, known for its agriculture departments, enology, and School of Veterinary Medicine, has one of the University's five medical schools, and along with those at Irvine and San Diego, was only a few years old at the time Allan Bakke applied for admission. Davis admitted its first medical students in 1968, beginning with 48 students in that year. As class size was increased, a special Task Force was also formed. Using the means of affirmative action to increase minority admissions, the Task Force was charged with filling 16 of the 100 seats with disadvantaged and minority students.

When Allan Bakke first applied for admission to Davis in 1973, affirmative action in higher education was hardly a new phenomenon. Bakke, applying as a Californian, faced even worse odds than most of his contemporaries in other parts of the country. A California applicant at the time had a 29% chance of being admitted, but those from the rest of the country had odds of 36%.

Affirmative action, a term widely used in the 1970s, was based on the assumption that equal opportunity and the selection of the best-qualified people were compatible goals. Such action, some believed, was, in the long run, in the best interests of society. Proponents of affirmative action maintained that only with a sensitivity to the needs of and equity for minorities could the proportion of minority students be increased in the realm of higher education. Opponents to any means of affirmative action called it reverse discrimination. The issues are very complex, but it is important to remember that preferential admissions have been part and parcel of college and professional school admissions for decades. Critics of affirmative action did not complain of reverse discrimination in the case of a speedy, 230-pound tight end with a C- average.

Allan Bakke was born in Minnesota in 1940 but moved with his family to Florida where he finished high school. He returned to his home state to study engineering at the University of Minnesota, graduating with a bachelor's degree in 1962. His 3.5 grade point average qualified him for election to the engineering honor society. Because the Navy had helped to pay for his education, Bakke served 4 years in the Marines, from 1963 to 1967, including a tour of duty in Vietnam. He was discharged as a captain. His first and only civilian job was working for the NASA (National Aeronautic and Space Administration) space program at the Ames Research Center in Sunnyvale, California. While working for NASA, he learned about space medicine and began to think seriously about combining his knowledge of mechanical engineering with medicine. In 1970, Bakke received a master's degree in engineering from Stanford and began to take the necessary courses to qualify himself for medical school application. He took these courses at Stanford and San Jose State University rather than at the local community college where the courses might have been less demanding for a person with a full-time job. He also took the Medical College Admission Test (MCAT) and scored very high grades on all but one of the four parts.

In 1972, he applied to the medical schools at Northwestern and the University of Southern California and was turned down by both because of his age; at the time he was 32 years old. In 1973, taking no chances this time, he applied to 12 medical schools and again was turned down by all of them. One of the 12 schools was the University of California at Davis, where he thought he might have a much better chance than at the older, more prestigious medical school of the University of California at San Francisco, to which he had also applied.

Judging by the letters that he wrote, and by his personal statement in the application, Bakke clearly had a passionate desire to study medicine. "I have an excellent job in engineering and am well-paid," he wrote. "I don't wish to change careers for financial gain, but because I truly believe my contribution to society can be much greater as a physician-engineer than in my present field" [9]. Bakke did not complete his Davis application until January 1973 because of his mother-in-law's terminal illness, and so he was not interviewed until 21 March. This was late in the season, and most of the class that would matriculate that fall had already received their acceptance notices. Nevertheless, the interview seemed to have gone well. The interviewer, a faculty member from the Department of Pharmacology, wrote an extremely favorable interview note that concluded, "On the grounds of motivation, academic record, potential promise,. personal appearance and demeanor, maturity and probable contribution to balance in the class, I believe that Mr. Bakke must be considered as a very desirable applicant to this medical school and I shall so recommend him" [8, 11].

The interviewer, however, does not make the decision for acceptance. That is usually made by a committee on which the interviewer may sit. Because the composite scores by which the Davis committee evaluated their candidates were not as high as this summary might have indicated and probably because it was so late in the admissions season, Bakke was rejected. His was 1 of 2464 applications for the 100 places in the Davis class, for which the school accepted 160 in order to end up with 100 students.

Bakke received a form letter dated 14 May 1973 telling him that Davis had rejected his application. He had also been refused by 11 other schools to which he had applied that year. The Davis rejection was particularly disappointing to him because he felt that his chances had been better there than elsewhere. Still passionately hoping to study medicine, Bakke wrote a letter to the Admissions Office at Davis, inquiring whether there was any possibility that he might still be put on a waiting list of some kind. He received no answer to this inquiry, a serious and unfortunate lapse on the part of the university. Meanwhile, it became evident to Bakke that Davis gave preference to minority students whose grades and MCAT scores he believed were well below his own.

Receiving no answer to his letter telling Davis that he was still very much hoping to be admitted to the medical school, Bakke wrote another letter on 1 July; this second letter included two sentences that would play an important role in his reapplication the following year. In it, Bakke questioned the use of quotas in the admissions process, and he included a telling sentence: "I feel compelled to pursue a further course of action" [8, 11].

A young staff member of the Admissions Committee, Peter Storandt, was given the task of answering Bakke. Thus began an active correspondence between the two. Storandt, a few years younger than Bakke, would later claim that it was his job to counsel all applicants who appealed for assistance and that he treated Bakke no differently than he treated others [12]. However, as it turned out, Storandt sympathized with Bakke's plight, believed that the NASA engineer was a very good applicant, and urged him to apply for early decision the next year. Storandt readily admitted that the DeFunis case, then being widely discussed in university and admissions circles, had come up in their correspondence. He advised Bakke to apply one more time to Davis before resorting to legal action, but Storandt did write to Bakke that a similar case with a clearer ruling might, in the end, serve medical education well. In August 1973, for instance, Storandt wrote to Bakke, "It seems to me that you have carefully arranged your thinking about this matter and that the eventual result of your next actions will be of significance to many present and future medical school applicants" [8].

Storandt later denied that he told Bakke that Dr. John Tupper, Dean of Medicine at Davis, admitted students under a special preference as favors to donors, alumni, and political figures such as members of the State Legislature or heads of county medical societies. A special inquiry, reported in the press, had shown that each year about 4 students, or 4% of the class, were admitted in this way. Storandt, in a letter to The New York Times in 1977 [12], wrote that in his 3 years at Davis, 12 students had been admitted by the Dean's "special admissions program". This practice was not uncommon at some other medical schools but is obviously extremely difficult to document with precision. In any case, the practice came to an end at Davis in 1977 because of much unfavorable publicity.

It is clear from the letters that Bakke wrote to Storandt and from his reapplication to Davis filed promptly in the early summer of 1974 that his goal was to be admitted. "My first concern," he wrote to Storandt, "is to be allowed to study medicine, and. challenging the concept of racial quotas is secondary" [9]. Conditions for Bakke the second time around at Davis were no easier than they had been the previous year. Because Davis was now using the recently established American Medical Colleges Application Service (AMCAS), a centralized computer-based means of applying to numerous medical schools by filling out only one application form, Davis received 3737 applications in 1974, as compared with 2464 the year before. Nationally, too, in 1974, Bakke hit the highest peak of medical school applicants ever recorded, only exceeded by the applicant year for the class entering September 1993. In 1974, there were 628 Task Force or minority applicants to Davis. One hundred seventy-two of them were white, but, as was true in 1973 as well, none of the white applicants was admitted. The school also changed its interviewing procedure to include two interviews of the candidates deemed probably acceptable. One interview was carried out by a student member of the Admissions Committee, and the second was done by a faculty member.

Bakke's application for early decision was not much changed from the one he submitted in 1973, with the exception of the timing. The student who interviewed him admitted that after reading the file he had formed a poor impression of Bakke, presumably because the applicant had by this time been identified as a potential source of trouble for Davis. The interview, however, seems to have gone well, because the student interviewer found Bakke to be "friendly, well-tempered, conscientious, and delightful to speak with [9]".

The second interview was a different story. Dr. George Lowrey, a pediatrician and assistant dean for admissions, was the interviewer, and he, predictably, was not particularly friendly to the candidate. Lowrey later testified that it was the luck of the draw that determined who interviewed Bakke that year. To any experienced member of admissions committees, that seems highly unlikely. In any case, Lowrey's opinion of Bakke differed markedly from that of his student colleague in 1974 and particularly from that of his faculty colleague in the previous year. Lowrey wrote in his interview note that he found Bakke "a rather rigidly oriented young man who has the tendency to arrive at conclusions based more upon his personal impression than upon thoughtful processes using available sources of information. This may be a rather severe criticism, but I certainly felt this way about him. I do believe that his motivation is a strong one and I further believe that his academic record supports his ability to do good work in medical school. I imagine that he would be a very hard worker, but that he would have a tendency to do things by the book and would have difficulty reaching independent conclusions. I would rate him acceptable, but certainly not an outstanding candidate for our school" [9].

So much for the scientific character of the admissions process. To be 1 of about 160 students chosen from a group of nearly 4000, it is clear that "acceptable but not outstanding" would hardly suffice for admission. Just as was the case when many Jewish students had trouble gaining admission to the medical schools in the mid-1930s, to be characterized as a "hard worker" was a pejorative assessment.

Bakke was denied early admission, but his application was held over to be reconsidered with those of the entire pool of applicants; he was denied later as well. He filed suit in California Superior Court, asking to be admitted on the basis of equal protection under the Fourteenth Amendment, because Davis admitted each year 16 students whose scores and grades were indeed lower than Bakke's or those of the applicants admitted in the general process. Bakke's principal aim in resorting to the courts was to gain admission, but inevitably the case turned on the legality of the special process used by Davis. That it openly reserved 16 spots for the Task Force and that none of the whites who had applied for admission through it was ever admitted greatly weakened the University's case.

The Bakke case wound its way through the California courts and to the U.S. Supreme Court, which ruled in 1978 that the University could use race as one of the factors in admissions policies. However, the court also found that Mr. Bakke's rights under the Fourteenth Amendment, which guaranteed equal protection, had been infringed. The court ordered that he be admitted to Davis for the class beginning in the fall of 1978. Bakke graduated 4 years later and is now practicing anesthesiology in Rochester, Minnesota.

The Path to Medical School

This is not the place to review once again all of the implications that the Bakke case has had. It is worth pointing out, however, that Allan Bakke's obstacles in his long quest to become a medical student included not just the competition from minority students also striving for admission. In his case, 20% of the places in his intended medical school class were filled through a process to which he had no access (16 places through the Task Force and 4 through the Dean's office). But even more important, the substantial increase in young white women applying to medical schools also added a significant measure to the competition.

What do our three cases tell us about admission to medical school in the 20th century? First and foremost, just as there never was only one kind of medical student, so there is and never was an entirely typical medical school admissions process. This became especially true once applicants were forced to compete for a place that was not equally available to all who wished to attend medical school. The era of George Minot, when anyone with a matriculation fee in hand could march up to the registrar's desk and enroll, had less variability in the admissions process than does the current era.

These three examples, chosen from dozens I could describe, show a remarkable diversity in the path to medical school and provide insight into the various educational, professional, and social issues that underlie what may appear as simply the process of getting into medical school. Themes touched on in these three stories include family influence, the problems of women and minorities, affirmative action, preferential admissions, the vagaries of the interview, and the problems of the older applicant. We could expand the list, and in my book I will certainly expand the discussion of these and similar themes.

The answer to the question posed in the title to this article is not so readily apparent as it may seem at first glance. When it was easier to get into medical school, was society better served? As we continue to discuss how many doctors we should have, what kinds of people we want as our physicians, and how they should be prepared before entering the study of medicine, do we really plan for the public good? The issue of exclusion in our society is a subject that cries out for more historical study. Restricted and selective admission to professional schools are but two manifestations of exclusion. There is an important book to be written about the related themes of exclusion and separation. We have separated and excluded in many of our social institutions and social processes, such as in civil rights pertaining to voting, juries, and schools. We have created separate institutions for the poor, the sick, the feeble-minded, orphans, and criminals. We have quarantined for the protection of society, just as we have incarcerated those thought to be dangerous by virtue of their mental state or their criminal behavior. We have segregated our schools, clubs, and neighborhoods on the basis of race and social class, and we have provided privileges through membership in unions and guilds that may have had exclusionary rules for joining.

Medical school attendance, since the late 19th century, has been necessary for admission to the medical profession and to the right to practice. Admission to medical school has become an expensive and ritualized process, but it is also an exclusionary one. Only a chosen few earn the privileges of professional status. Viewed in this larger context, the preparation for medical education is but one aspect of a far vaster set of social activities.

Lest we believe that we have simple answers to such complicated questions as "good for whom?", I will close with an admission from one of the wisest of physicians and one who also played a continuing role in the life and work of Nick Davies. In 1911, when he read a brief report about The Johns Hopkins School of Medicine written by Abraham Flexner for the Rockefeller philanthropies, William Osler wrote from Oxford to his former Baltimore colleague Ira Remsen, who had become President of the University. Osler found Flexner's arguments for a full-time system for the clinical faculty to be misguided. He also admitted the following: "We are all for sale, dear Remsen. You and I have been in the market for years, and have loved to buy and sell our wares in brains and books—it has been our life. So with institutions. It is always pleasant to be bought, when the purchase price does not involve the sacrifice of an essential—as was the case in that happy purchase of us by the Women's Education Association ..." [13]. What Nick Davies excelled in, and where the humanities can help all of us, is in figuring out what the essentials are.