The Impact of the Physician Letter of Recommendation
on Medical School Admissions Demographics
Justin Fox (OMS-III), John Burgess (OMS-III), Alexis Stoner PhD, MPH, Harold Garner, Phd, Heather Bendyk,
MBA, CPHQ
VCOM, Spartanburg, SC
Co-authorship should be given to collaborators such as a Statistician, who have made intellectual contribution in terms of writing,
research design, study implementation, and data analysis and interpretation.
Abstract Results Results
Context: Some ethnic groups are underrepresented in the medical field because they face unique
barriers to admission to medical school. These barriers are due to social determinants, as well of the
difficulty of the application process itself. One admission requirement that can present a barrier for
applicants is the physician letter of recommendation (PLOR).
Objective: To determine if a relationship exists between a PLOR requirement and the proportion of
underrepresented minorities (URM’s) in medical school.
Methods: A descriptive study was conducted using 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. Schools were
grouped based on whether they required a PLOR. For each group of schools, means were assessed for
the following outcomes: 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 matriculants per ethnicity. A Wilcoxon rank-sum test was used to
determine the significance of the differences between the group means. A p-value of less than 0.05 was
considered significant. 95% confidence intervals were calculated, and overlapping intervals were
considered insignificant values.
Results: On average, schools that require a PLOR have 23% less total applicants and have smaller class
sizes overall. Black students showed significant reductions (p<.05) across all measured outcomes. Most
notably, mean number of matriculants and mean matriculation percentage fell by 50%.
Conclusion: PLOR requirements are inversely related to the diversity of medical school student bodies.
References
1) The number of black students is significantly reduced (p<.0001) across all measured outcomes when
a PLOR is required. Notably, mean matriculation percentage fell by 50%.
2) On average, schools that do not require a PLOR have more applicants and larger class sizes.
3) Student bodies at medical schools with PLOR requirements show lower ethnic diversity than those
that do not.
4) Creates a justification for further consideration on the need for physician’s letter of recommendation
in the application process, and if the intended benefits outweigh the evident risks.
Future research should continue to explore this topic by assessing current students' application
experiences, how students are obtaining their PLOR, and if PLORs are more difficult for all people of
lower socioeconomic status or just those who are URM. The global coronavirus pandemic also offers a
rare opportunity to investigate how the diversity of applicants/matriculants at each school was affected
by many schools’ decision to waive their PLOR requirements due to COVID-19..
Robinett K, Kareem R, Reavis K, Quezada S. A multi‐pronged, antiracist approach to optimize
equity in medical school admissions. Medical Education. 2021;55(12):1376–82.
U.S. Census Bureau quickfacts: United States [Internet]. [cited 2021Dec1]. Available from:
https://www.census.gov/quickfacts/fact/table/US/PST045219
Chart 1: Applicants, first-time applicants, and ... - aamc.org [Internet]. [cited 2021Dec2].
Available from: https://www.aamc.org/media/9581/download?attachment
Wouters A. Getting to know our non-traditional and rejected medical school applicants.
Perspectives on Medical Education. 2020;9(3):132–4.
Rao V, Flores G. Why aren't there more African-American physicians? A qualitative study and
exploratory inquiry of African-American students' perspectives on careers in medicine. J Natl
Med Assoc. 2007;99(9):986-993.
Joseph J, Dao D, Hwang SM, Dotzler SM, Chesak SS, Weiskittel TM, et al. Perceptions of barriers
and facilitators to becoming a medical professional among underrepresented undergraduate
and postbaccalaureate learners. Mayo Clinic Proceedings: Innovations, Quality & Outcomes.
2021;5(2):347–58.
Agrawal JR, Vlaicu S, Carrasquillo O. Progress and pitfalls in underrepresented minority
recruitment: perspectives from the medical schools. J Natl Med Assoc. 2005 Sep;97(9):1226-
31. PMID: 16296213; PMCID: PMC2594778.
Implicit racial bias - JRSA [Internet]. [cited 2021Dec2]. Available from:
https://www.jrsa.org/pubs/factsheets/jrsa-factsheet-implicit-racial-bias.pdf
AACOMAS Applicants and Matriculants by Race and Ethnicity [Internet]. AACOMAS {cited
2021Dec2]. Available from: https://www.aacom.org/docs/default-source/data-and-
trends/2020-aacomas-applicant-matriculant-profile-summary-report.pdf
Dr. Stoner for her guidance and patience
Dr. Cashman, DO for believing in this idea before anyone else gave it the time of day
Dr. Colbath, MD for writing my PLOR back when he was the only physician I knew.
Acknowledgements
Background and Introduction
Table 3 Average Number of Applicants/Matriculants of given Race/Ethnicity
Table 4. Mean Percent of Applicants/Matriculants Comprised of Given Ethnicity
Race/Ethnicity
Conclusions
Figure 2: Outcomes for Black Students
Despite efforts to increase the number of URM students entering the medical
profession, the percentage of medical students who belong to a URM group has not improved
significantly in nearly a half century. In 1998-1999 allopathic medical schools were 15.2%
URM. Now, more than twenty years later… (see Table 1)
In total, 35 osteopathic schools with 44
campuses were included in the study
(two schools were not included in the
study because they used an independent
application service). Using each school’s
website, DO and MD schools were group
based on their letter requirement. We
found that:
• 78%, (29/35) of DO schools
required a PLOR
• 4% (6/155) of MD schools required
a PLOR
• The standardization of a PLOR
requirement is unique to DO
schools.
Table 2: Collective Outcomes
Table 2 -This table contains averages of matriculation, application, and rates of acceptance of various demographic
groups at osteopathic medical schools. The averages are separated by schools that require a physician letter of
recommendation and schools that do not require one. Bold = significant.
Table 1:
Table 1 – the demographic composition of matriculants to DO
and MD schools in 2020 compared to the population of the
United States that year.
To better understand the unique
barriers that URM students face when
pursuing a career in medicine, the
authors conducted a literature review
posing this question. A summary of
those findings is graphically displayed
in Figure 1.
Table 2 shows that there was not a large enough sample size to produce a statically
significant result for either the Indigenous or the Islander group of student applicants. It also
shows that on average, schools that require a PLOR have 23% less total applicants and have 17%
smaller class sizes. When considering URM students as a whole, all means trended toward
increased diversity in the absence of a PLOR requirement, however the p-values only indicate
statistically significant increases in the number of URM applicants and URM matriculants to
schools that did not require PLORs. Black students showed significant decreases across all
measured outcomes . In contrast to the other race/ethnicities, Hispanic students represented a
greater percentage of applicants and matriculated at a higher rate to schools that do require a
PLOR. The p-values indicate statistical significance, but the 95% confidence intervals are
overlapped by a very slim margin. We cannot state with certainty the significance of this finding. It
is clear, however, that Hispanics react differently to PLOR requirements than Black students, and
it’s likely that they benefit from them.
The results of this study show that obtaining a PLOR is a barrier for medical school
applicants of any background. It strongly indicates a relationship between mandatory PLOR’s and
the number of URMs matriculating. PLORs are associated with decreasing diversity in medical
school matriculants, especially amongst black students. Difficulty getting a PLOR can be a
consequence of or reflective of the already recognized barriers that URM students confront.
Increasing diversity in medical students would require us to make changes to some of the
current processes and procedures to ensure equitable opportunity for all students. A racially and
ethnically diverse student body is a critical element in educating physicians to meet the needs of a
diverse society.
Figure 1:
