Medical Education Original Article
Justin Fox, BS, MS, John Burgess, BS, Alexis M. Stoner*, PhD, MPH, Harold Garner, PhD
and Heather Bendyk, MPH, CPHQ
The relationship between required physician
letters of recommendation and decreasing
diversity in osteopathic medical school
admissions
https://doi.org/10.1515/jom-2022-0112
Received May 27, 2022; accepted February 24, 2023;
published online March 21, 2023
Abstract
Context: Some racial and ethnic groups are underrepre-
sented 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 Osteo-
pathic 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 oste-
opathic 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 ap-
plicants, class size, application rate per ethnicity, matricula-
tion 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. Statis-
tical 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 re-
ductions 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 osteo-
pathic medical schools.
Keyword: diversity; letter of recommendation; medical
education; medical school admissions.
Underrepresented in medicine (URM) are those ethnic
groups that are underrepresented in the medical field rela-
tive to their numbers in the entire population [1]. Despite
efforts by medical schools and government agencies to in-
crease 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 [2]. According to the US Census, individuals who
are URM make up 34.1% of the country’s population [3].
However, if we look at colleges of osteopathic medicine
(COMs), URM students comprised only 11.1% of matriculants
in 2020 [4]. The number of self-identifying Black students
*Corresponding author: Alexis M. Stoner, PhD, MPH, Associate Professor,
Discipline Chair for Preventive Medicine and Public Health, Edward Via
College of Osteopathic Medicine-Carolinas Campus, 350 Howard Street,
Spartanburg, SC 29303, USA, E-mail: astoner@carolinas.vcom.edu
Justin Fox, BS, MS, John Burgess, BS, Harold Garner, PhD and Heather
Bendyk, MPH, CPHQ, Edward Via College of Osteopathic Medicine-
Carolinas Campus, Spartanburg, SC, USA
J Osteopath Med 2023; 123(6): 287–293
Open Acces s. © 2023 the author(s), published by De Gruyter. This work is licensed under the Creative Commons Attribution 4.0 International License.
enrolling that same year was 3.3% [4] compared to 13.6% of
the US population that is Black [3]. Similarly, the percentage
of self-identifying Hispanic medical students, 7.6% [4], does
not approximate their population percentage of 18.9% [3].
Equity in medical school admission is important
because a racially and ethnically diverse student body is a
critical element in educating physicians to meet the needs of
a diverse society [5]. One study showed that White students
who attended schools that are within the highest quintile for
student body racial and ethnic diversity, measured by the
proportion of URM students, were more likely to rate
themselves as highly prepared to care for minority pop-
ulations than those in the lowest diversity quintile (61.1% vs.
53.9%, respectively; p<0.001; adjusted odds ratio [OR], 1.33;
95% confidence interval [CI], 1.13–1.57) [6]. The same study
also showed that URM students were substantially more
likely than white or nonwhite/non-URM students to plan to
serve the underserved (48.7% vs. 18.8% vs. 16.2%, respec-
tively; p<0.001) [6].
URM students face unique barriers to admission to
medical school due to social determinants: lack of financial
resources [7–9], educational disparities [8, 10], and lack of
mentorship [10–13]. In addition, many more are excluded by
the application process itself: implicit bias [14], emphasis of
Medical College Admission Test (MCAT) scores [10, 12, 15, 16],
lack of URM faculty [12, 13], and extensive application re-
quirements [10, 12]. Similar to the barriers presented in the
literature, one requirement that may present a barrier for
applicants, therefore warranting further study, is the
physician letter of recommendation (PLOR). In general, let-
ters of recommendation (LORs) are written to communicate
information about an individual to an institution [17]. They
communicate an applicant’s potential for success and
emphasize qualities not highlighted elsewhere in an appli-
cation [17]. Medical schools utilize shadowing experience
and PLORs to gauge an applicant’s interest in medicine and
to be sure that an applicant understands the career path on
which they are about to embark [18]. PLOR requirements
became common practice for osteopathic medical schools
because they wanted to ensure that their applicants under-
stood the principals of their profession and how their pro-
fession differs from allopathic medicine [18]. However, there
is a growing body of evidence to support the idea that LORs
have limited value to admission committees [19]. One study
that retrospectively analyzed three consecutive graduating
classes (2007–2009) of the Uniformed Services University of
the Health Sciences (USU) in Bethesda, Maryland analyzed
437 letters based on 76 LOR characteristics and found that
very few LOR characteristics predict how students perform
during medical school [20].
A review of the literature suggests that subjective
narrative LORs can act as a conduit of racism, sexism, and
bias into the admissions process [19, 21, 22], and many studies
have concluded that traditional narrative LORs are written
in prose utilizing highly subjective terminology with poor
inter-rater reliability when interpreted [23, 24]. Further-
more, opportunities to receive PLORs are not equal because
opportunities to shadow are not ubiquitous [25]. Many hos-
pital systems do not allow premedical student shadowing
because HIPAA restricts access to protected health infor-
mation to only those directly involved in healthcare opera-
tions activities [26]. According to a survey sent to all
matriculated medical students at the Philadelphia College of
Osteopathic Medicine (PCOM) and PCOM-Georgia for the
2017/2018 school year, a small number of students, 12.7% (43
out of 339) reported challenges with meeting this require-
ment, reporting that they had difficulty finding Doctor of
Osteopathic Medicine (DO) physicians to shadow [25]. “The
requirement to shadow and obtain a letter from a DO
physician is a well-intended mechanism to expose premed-
ical students to osteopathic medicine, but the requirement
may be a barrier to some students who are unable to find
shadowing experiences before medical school” [25].
Students who may not have a personal relationship with
a physician as a part of their family, faith community,
neighborhood association, or school parent-teacher organi-
zation, for example, have little choice but to rely on shad-
owing to secure a PLOR. URM applicants especially will have
less access to a PLOR because the fewer number of practicing
URM physicians means that there are fewer physicians who
are connected to this population of people outside of work.
Literature is currently lacking on the impact of the PLOR on
a student’s ability to apply to medical school and its outcome
on medical school admission demographics. The authors
hypothesized that students from rural, low-income, or mi-
nority backgrounds will apply and matriculate in fewer
numbers to schools that require a PLOR.
Methods
This research was determined exempt by the Edward Via College of
Osteopathic Medicine Institutional Review Board.
A retrospective study was conducted utilizing data published by
the American Association of Colleges of Osteopathic Medicine Applica-
tion Service (AACOMAS) on the race and ethnicity of applicants and
matriculants to COMs during the years 2009–2019. The study date range
was May 2009 to August 2019. The AACOMAS survey allowed students
to self-identify in predefined racial categories. URM students were
sorted into the following four racial/ethnic groups by the AACOMAS:
(1) Hispanic (Hispanic/Latino); (2) Black or African American;
288 Fox et al.: Physician letter of recommendation requirement on medical school diversity
(3) Indigenous (American Indian or Alaskan Native); and (4) Islander
(Native Hawaiian or Other Pacific Islander). Non-URM students refers to
those who selected either White, Asian, Unknown, or more than one
race/ethnicity. Students self-selected their race/ethnicity utilizing the
following method: “The race and ethnicity questions on the AACOMAS
application ask applicants to mark all that apply. For this report, race/
ethnicity was examined utilizing both: (1) single-category response,
where a single race/ethnicity is counted for each applicant, applicants
listing more than one race are reported as Multiple Races, and any
applicant who marked Hispanic/Latino is counted as being of Hispanic/
Latino ethnicity, effectively superseding any other race selection(s) s/he
may have made; and (2) multiple-category response, where each
applicant is counted for every race/ethnicity the applicant reported,
which may result in the applicant being counted multiple times” [4].
In total, 35 osteopathic schools with 44 campuses were included in
the study. There are 37 COMs total; however, two schools were not
included in this analysis because they are not included in the AACOMAS
database. Based on the application requirements stated on each school’s
unique website, schools were grouped based on whether they required a
PLOR or not. Twenty-nine schools with 36 campuses required a PLOR,
whereas only six schools with eight campuses did not.
Descriptive statistics were performed on the group means for the
following outcomes: number of total applicants, number of matricu-
lants, application rate per ethnicity (defined as number of applicants of
an race or ethnicity/total number of applicants), matriculation rate per
rate or ethnicity (defined as number matriculants of a race or ethnicity/
number of applicants of that race or ethnicity), number of applicants per
race or ethnicity, number of matriculants per race or ethnicity, and
percentage of matriculants per race or ethnicity (defined as number of
matriculants of a race or ethnicity/total matriculants). Ultimately, the
racial/ethnic diversity of a medical school’s admissions process was
measured by the percentage of applicants and the percentage of ma-
triculants to that program. The best way to conceptualize a difference in
diversity between groups separated by PLOR requirement is by
observing changes in percentage of applicants and matriculants.
Comparative analysis was utilized to assess differences between
the two groups of institutions. To account for the uneven group size, the
Wilcoxon rank-sum test was utilized to determine the significance of the
differences between the group means. This test is utilized to compare
two nonparametric and independent sample populations. A p value of
less than 0.05 was considered significant, 95% CIs were calculated, and
overlapping intervals were considered insignificant values.
Results
On average, schools that require a PLOR have 22.1% fewer
total applicants (4,164 vs. 5,345; p<0.0001) and have 15.8%
smaller class sizes (176 vs. 209; p<0.0001) (Table 1). When
considering only the group of URM students, all means
trended toward decreased diversity in the presence of a
PLOR requirement. However, the p values only indicate
statistically significant decreases in total number of appli-
cants (24.6%, 528.6 vs. 701.5, p<0.0001) and matriculants
(17.6%, 15.4 vs. 18.7, p<0.0001) of URM students to schools that
require PLORs (Table 1). The group of non-URM students
showed similarly significant decreases only in total number
of applicants (21.7%, 3635.8 vs. 4643.8, p<0.0001) and ma-
triculants (17.3%, 160.4 vs. 193.9, p<0.001) in the presence of a
PLOR requirement (Table 1).
Looking at each race individually, the group of Islander
students did not have a large enough sample size to produce
a statically significant difference in their prevalence be-
tween the groups of schools (Table 1). As a result, no con-
clusions were drawn about this group.
Indigenous students made up a greater percentage of
the total applicants to schools that require a PLOR (0.4 vs.
0.3%; p<0.027). No other results for this group were
significant.
Black students were the only ethnicity to show a sig-
nificant decrease across all measured outcomes: application
percentage (4.4 vs. 5.5%; p<0.0001), matriculation rate (2.2 vs.
2.8%; p=0.002), number of applicants (37.3%, 185 vs. 295;
p<0.0001), number of matriculants (51.2%, 4 vs. 8.2; p<0.0001),
and most notably a 47.7% decrease in the percentage of the
class comprised by Black students was observed in schools
that require a PLOR (2.3 vs. 4.4%; p<0.0001). These numbers
are graphically displayed in Figure 1.
In contrast to Black students, when focusing on the
Hispanic students, they represented a greater percentage of
applicants and greater matriculant rate to schools that do
require a PLOR (Table 1). In each case, there is less than a 1%
difference between the groups, and although p values indi-
cated statistical significance, the 95% CIs overlap by a very
slim margin.
Discussion
The results of this study indicate that a relationship exists
between a medical school requiring a PLOR and the per-
centage of URMs matriculating. It also provides evidence to
suggest that obtaining a PLOR is a barrier for medical school
applicants of any background. This study adds to the litera-
ture by illustrating an association between PLORs and
decreasing diversity in medical school matriculants.
While we did see a large impact on Black applicants, the
results indicate that the Hispanic population was not as
impacted by the PLOR requirement. The term “Hispanic”
includes both those of European descent and those of South
American descent. Because it is an ethnicity and not a race
[27], it could not accurately be compared to the other pop-
ulations of students in this study. The authors recommend
that organizations make more of an effort to distinguish
South American Hispanic from European Hispanic to more
intentionally target the community of people who are most
disenfranchised.
Fox et al.: Physician letter of recommendation requirement on medical school diversity 289
Although requiring a PLOR is very common practice
among osteopathic medical schools, with 81.8% (36 out of 44)
requiring it, it is rare among allopathic schools, with 3.9% (6
out of 154) requiring a PLOR. Allopathic medical schools only
require LORs from a student ’s undergraduate institution
and strongly recom mend a clinical letter but do not
require it. According to the Association of American
Medical Colleges (AAMC), allopathic schools matriculated
14.6% URM students in the year 2020 [28], compared to
11.1% URM students at osteopathic schools [4]. They also
Table : 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 PLOR and schools that do not require one.
Variable Does not require PLOR Requires PLOR p-Value
Mean (% CI) Mean (% CI)
Number of matriculants
Total . (.–.) . (.–.) <.
Hispanic . (.–.) . (.–.) .
Black . (.–.) . (.–.) <.
Indigenous .
(.–.) . (.–.) .
Islander . (.–.) . (.–.) .
URM . (.–.) . (.–.) <.
Non-URM . (.–.) . (.
–.) .
Percentage of matriculants
Hispanic .%(.–.) .%(.–. .
Black .% (.–.) .% (.–.) <.
Indigenous .%(.–.) .%(.–.) .
Islander .%(
.–.) .%(.–.) .
URM .%(.–.) .%(.–.) .
Non-URM .%(.–.) .%(.–.) .
Number of applicants
Total ,. (,.–,.) ,
. (,.–,.) <.
Hispanic . (.–.) . (–.) .
Black . (–.) . (.–.) <.
Indigenous . (.–.) . (.–.) .
Islander
. (.–.) . (.–.) .
URM . (.–.) . (.–.) <.
Non-URM ,. (,.–,.) ,. (,.–,) <.
Percentage of applicants
Hispanic .%(
.–.) .%(.–.) .
Black .% (.–.) .% (.–.) <.
Indigenous .% (.–.) .% (.–.) .
Islander .%(.–.) .%(
.–.) .
URM .%(.–.) .%(.–.) .
Non-URM .%(.–.) .%(.–.) .
Matriculation rate
Total .% (.–.) .% (.–.) .
Hispanic .
%(.–.) .%(.–.) .
Black .% (.–.) .% (.–.) .
Indigenous .%(.–.) .%(.–.) .
Islander .%(.–.) .%(
.–.) .
URM .%(.–.) .%(.–.) .
Non-URM .% (.–.) .% (.–.) .
CI, confidence interval; PLOR, physician letter of recommendation; URM, underrepresented in medicine. The values that are bolded are those that represent
statistically significant results.
290 Fox et al.: Physician letter of recommendation requirement on medical school diversity
had more than d ouble the percentage of Black matricu-
lants (7.6 vs. 3.3%) [4, 28].
Difficulty getting a PLOR can be a consequence of or
reflective of the already-recognized barriers that URM stu-
dents confront. An effort to increase racial/ethnic diversity
in medical students requires us to make changes to some of
the current processes and procedures to ensure equitable
opportunity for all students. Current interventions have
focused on unconscious bias training for interviewers [14, 29],
holistic review of applicants [12, 15, 29], peer-to-peer men-
toring [22], creating pipeline/enrichment programs
[10–12], and increas ing minority faculty [12 , 29]. The results
of our study indicate that reconsidering a required PLOR
may add additional benefittothiseffort.
Removal of a PLOR requirement would come at little
cost to the quality of the osteopathic admissions process and
could help to further diversify their applicant pool.
Increasing diversity among the medical student population
is essential to building a physician population that is more
representative of the population of the United States [3].
Furthermore, evidence has indicated that diversity im-
proves the accuracy of clinical decision making, leading to
higher patient satisfaction and resulting in improved health
outcomes [30].
An important limitation is that the data did not include
the number of students that were accepted to a given school
but did not matriculate to that school because they were also
accepted to another school. This gap in knowledge can easily
be overcome in the future collaboration and input from
each COM. Additional confounding factors that were not
controlled for and should also be considered when inter-
preting the results of this study include school location,
location demographics, scholarship awards, and mission
statement that might influence a student’s decision to attend.
Location of a school and the demographics of that area is
of interest because all six of the schools that did not require a
PLOR are located on the eastern half of the United States [31].
They are located in the top eight states when ranked by
percentage of practicing DO physicians [32]. Given the re-
sults of our study, this correlates to schools in states with
more DOs having a higher percentage of URM applicants.
This can be interpreted as supporting our hypothesis that
access to physicians encourages more applications to medi-
cal school but could also be seen as a confounding factor.
Future research is needed to assess the effects of geography
on URM applications to a medical school with respect to
PLOR requirements.
For a further example of the effects of location, there is a
much higher population density of Native Americans in the
Western and Midwestern states than in the eastern half of the
United States (Arizona, Oklahoma, New Mexico) [33]. If one
assumes that indigenous students applied to schools in their
region more so than those further away, then it is possible
that this would inadvertently increase the percentage of
Indigenous applicants to schools that require PLORs. A future
study could take a closer look at this phenomenon.
Furthermore, state-funded osteopathic medical schools
often must meet quotas that require a certain percentage of
their class size to be filled by students who reside in that
state. Schools often have a mission to increase the number of
physicians who practice in their state. Therefore, the de-
mographics of a state may impact the demographics of their
matriculants.
Finally, another important confounding factor that was
not controlled for and should be considered when inter-
preting the results of this study is that some schools are more
attractive to URM students because they offer scholarship
awards specifically for them.
Figure 1: This figure displays all of the
measured outcomes of this study for Black
students. It shows a decrease in matriculation
rate, the percent of matriculants, the percent
of applicants, the number of matriculants, and
the number of applicants of Black students at
schools requiring a PLOR. A p value <0.05 for
all outcomes.
Fox et al.: Physician letter of recommendation requirement on medical school diversity 291
Conclusions
To the best of our knowledge, this is the first study to explore
the impact of the required PLOR on diversity in medical
schools. Future research should continue to explore this
topic through the assessment of accepted and recently
graduated students’ application experiences, specifically
how students obtain their PLOR, barriers if any to obtaining
the letter, the duration of shadowing experiences, and more
individual demographic data. A study of this methodology
will help us to evaluate PLORs as a barrier for students
grouped by factors such as socioeconomic status and the
location of their hometown, not just their URM status.
Additionally, examining the diversity of osteopathic
medical school applicants following the COVID-19 pandemic
will help us understand the influence of the required PLOR.
Due to the pandemic, some medical schools waived the
requirement of a PLOR because shadowing opportunities
were severely limited due to many hospitals not allowing
shadowing as a measure to slow the spread of the virus.
The data from this research is a crucial first step in
helping to guide medical school admissions departments
regarding the impact of the PLOR. It suggests that the PLOR
requirement is an additional barrier for students entering
medical school, one that disproportionally affects Black
students. Based on this result, it is recommended that the
PLOR requirement for application to osteopathic medical
schools be discontinued, pending research that shows
otherwise or until access to physicians is equally ubiquitous
Research funding: None reported.
Author contributions: All authors provided substantial
contributions to conception and design, acquisition of data,
or analysis and interpretation of data; all authors drafted the
article or revised it critically for important intellectual content;
all authors contributed to the analysis and interpretation of
data; all authors gave final approval of the version of the
articletobepublished;andallauthors agree to be accountable
for all aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Competing interests: None reported.
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