Making decisions about whom to admit to medical school and how to create diversity in the process has come under increased scrutiny. An additional layer of complexity is introduced when committees utilize the AAMC's prescribed holistic review in addition to their institutional diversity policies. This comparative case study explores how two medical schools (one public and one private) are charged with implementing holistic review when challenged by the institutional culture which may resist a holistic approach. Through interviews, meeting observations, and document analysis, the study examines how and when diversity is introduced into the admissions process, and how diversity policies function in the overall medical school environment. Applying a framework of institutional isomorphism (DiMaggio & Powell, 1983), the study found that medical schools are highly concerned about a decrease in MCAT scores and coursework grades, which could negatively impact medical school rankings. It could also contribute to institutional inertia when introducing a new review process, causing resistance by admissions committee members. Additionally, admissions committees and leadership may differ regarding philosophical and historical factors that create bias within the process resulting in isomorphic change. Isomorphic change is a result of the ambiguity and the lack of institutional buy-in on various levels (DiMaggio & Powell, 1983). Virtual adoption (Birnbaum, 2000) is a result of an increased focus emulating processes of peer medical schools that misalign the school's priorities, creating confusion about how to address the national shortage of diverse physicians. Future research needs to account for additional influences on admissions decisions, including the impact of the current Fisher v. University of Texas case that may redefine how diversity is measured in medical school admissions.