Physicians Less Likely to Feel Happy Outside of Work

The covid-19 pandemic has caused significant stress to medical caregivers. And it extends beyond their professional lives. Medscape’s 2022 Physician Lifestyle and Happiness report provides insight into physicians’ habits, downtime, work-life balance, and relationships, and includes responses from more than 10,000 U.S. physicians representing almost 30 specialties. 

When asked about their life prior to the pandemic, eight in ten physicians reported that they were very (40 percent) or somewhat (41 percent) happy outside of work. Now, fewer than six in ten say that they are happy outside of work. Just 24 percent say they are very happy and 35 percent are somewhat happy. And, notably, just one-third of respondents feel that they have enough time (always or usually) to spend on their own health and wellness, with men more likely to have time (38 percent) than women (27 percent). Just under half of physicians, 44 percent, “sometimes” have the time to focus on their own wellbeing.

To maintain their happiness and mental health, most physicians say that they spend time with family/friends (68 percent), engage in activities/enjoyable hobbies (66 percent), and exercise (63 percent). Just under half say they focus on getting enough sleep (49 percent) and eating healthy (44 percent). The majority of physicians do say that they exercise regularly—34 percent exercise two to three times a week and 33 percent exercise four or more times a week.  When asked about weight, about one-third say that they are working to maintain their current weight (30 percent), while just over half are looking to lose weight (51 percent). 

Over half of physicians, 55 percent, say that they would take a salary reduction to have a better work-life balance, an increase of eight percentage points from 47 percent a year ago. Female physicians are more likely to express a willingness to take a pay cut for improved work-life balance, with 60 percent saying they would give up salary for balance compared to 53 percent of men. In terms of time away from work, most physicians take between one and four weeks of vacation; 30 percent take one to two weeks and 40 percent take three to four weeks. These numbers are similar to last year’s report. 

Most physicians are married or in a committed relationship (89 percent of men, 75 percent of women). And the majority, 82 percent, describe their marriage as very good or good, which is similar to last year. While the percentages are high across specialties, 91 percent of otolaryngologists and immunologists describe their unions as good or very good, while critical care (76 percent) and plastic surgery (75 percent) fall on the lower side. Forty-three percent of physicians are married to another physician or healthcare worker, though the majority (56 percent) are married to a partner outside of medicine. Among physicians who are parents, 35 percent feel conflicted between work and family demands. Almost half of female physicians, 48 percent, are conflicted or very conflicted, whereas 29 percent of their male counterparts report feeling the same. About 30 percent of both men and women physicians report feeling somewhat conflicted.

Physician wellbeing is critical for preventing burnout, particularly in the aftermath of the pandemic, as burnout levels remain high and directly impact the quality of care provided to patients. The AMA has taken on the topic of physician burnout to spur advocacy, research, and provide tactical resources to improve wellbeing, which prospective and current medical students may wish to review. Medical students should strive to integrate wellbeing practices into their lifestyles as early as possible—healthy dietary and movement habits, outlets for stress, and strong relationships that may help them to withstand the stress of medical school and patient care.

Medical Schools Train Students to Combat Medical Misinformation

Earlier this month, the University of Pennsylvania announced the Penn Medical Communication Research Institute (PMCRI), a collaboration between the Annenberg School for Communication and the Perelman School of Medicine, which will focus on reducing medical misinformation. The Institute will research methods for patients, particularly within vulnerable groups, to access reliable, useful medical information and develop strategies to increase the trust of healthcare providers and the scientific community.

The Institute is reflective of a growing momentum within medical education focused on combating medical and scientific misinformation. Schools are exploring a variety of methods to achieve this.

Brian G. Southwell, PhD, and Jamie L. Wood, PhD, Co-Directors of the Duke Program on Medical Misinformation, and Ann Marie Navar, MD, PhD, wrote in the American Journal of Public Health that, “Encountering patient-held misinformation offers an opportunity for clinicians to learn about patient values, preferences, comprehension, and information diets. Systematically training health care professionals to address patient-held misinformation with empathy and curiosity, acknowledging time and resource constraints, will be a crucial contribution toward future mitigation of medical misinformation.” In turn, Duke’s program, a part of the Duke Center for Community and Population Health Improvement, shares provider guidelines that promote developing “psychologically safe” relationships with patients. In other words, the patients should feel comfortable sharing the information and sources that they use to make medical decisions with their physicians and caregivers without fear of judgment or ridicule. Once physicians and the care team understand where the patient is coming from, they can provide support and guidance to correct misinformation and provide alternative, credible sources.

Other schools are incorporating communication techniques into the medical curriculum so that students can acquire the skills they need to reach broader audiences.

Last Spring at University of Chicago’s Prtizker Medical School, Vineet Arora, MD, MAPP and Sara Serritella, the Director of Communications at the Institute for Translational Medicine, developed and co-taught an elective course for first-year medical students titled, “Improving Scientific Communication and Addressing Misinformation.” Serritella, speaking to the critical nature of the course, cited a 2016 study by the National Science Foundation in which less than one-third of respondents said that they had a “clear understanding” of the meaning of “scientific study.” Medical students, she continued, need awareness of the gap between their understanding and that of the general public so that they can effectively bridge it. The course focused on teaching students the principles of scientific communication, how to identify misinformation, and how to debunk misinformation using infographics. But, more than that, it asked students to consider various audiences and ways to share information that were relatable, understandable, and relevant to those groups. Arora noted that students are well-positioned to play a key role in combating misinformation. “Addressing medical misinformation using evidence-based strategies is one way that medical students can add value and also learn a lifelong skill they will need to improve communication and trust in medical care for their patients,” he said.

At the University of Minnesota, Dr. Kristina Krohn, MD, an assistant professor in the Department of Medicine, saw a social media-specific need that medical students were well-positioned to breach in the early days of the pandemic. In the Spring of 2020, she developed an elective course titled “COVID-19: Outbreaks and the Media” that is still available. The goal of the course is to enable students to leverage social media to relay health information to the public. While the course offered general communications information including defining an objective and creating infographics, it also included basics such as how to create social media accounts, fact-check data, translate scientific literature into layman terms, and relay accurate information in simple, compelling ways… all via social media. Dr. Kohn explains the reasoning behind the course for medical students: “If we share publicly our knowledge in formats that are open and available to the public, we help people make better choices sooner, but we don’t learn how to do that in medical school. I think it’s a huge skill that we’ve overlooked, and social media has made it so that a medical student can do this. We just need to help them do it well and give them the appropriate teaching and tools,” she said.  

Medical Students Offer Recommendations to Improve Medical Schools’ Ability to Promote Student Wellbeing

A group of medical students (Marie Walters, PhD, MPhil, MD1; Taiwo Alonge, MD, MPH2; and Matthew Zeller, DO3) recently published an article in Academic Medicine describing the challenges medical students have navigated during the pandemic. They noted that while some pandemic-era challenges were unprecedented, long-standing issues were also brought to light, and that medical schools can use learnings from this period to implement reforms that promote mental health and wellbeing within the medical student population.

Below are the authors’ recommendations. You can find the full article here. 

Improving Communications: The pandemic and the “intensified sociopolitical conflicts” affected students’ wellbeing and academic focus, and amplified the need for timely and transparent communications. The authors recommend that administrative leaders partner with student government to provide information, facilitate frequent and consistent town hall meetings, and incorporate the CDC Crisis Emergency Risk Communication (CERC) guidelines into communications. 

Adapting Preclinical Education: Prior to the pandemic, medical schools required students to attend daily, in-person activities that made follow through on any personal commitments difficult. The move to online learning provided flexibility, but it created a lack of differentiation between school and free time. It also created uncertainties around the curriculum’s ability to properly train and assess students in preclinical skills (e.g., physical exams, dissections). The authors recommend that schools maintain flexibility by making recordings of learning activities accessible to all students, provide discounts for proprietary study materials, remove attendance requirements and associated limited access to course materials, and continue to promote virtual networking spaces. 

Enhancing Support Services: An increasing number of medical students reported signs of burnout and some students, from communities more heavily impacted by the pandemic, were unable to return home for funerals or to assist with caretaker responsibilities. Student isolation made it difficult to find support from community, mental health, or wellbeing services. The authors recommend that schools put in place formal mental health checks for students, increase access to mental health support, and, should purely virtual learning need to occur again, offer virtual group clinical opportunities and study sessions.

Adapting Clinical Education: Pre-pandemic, many schools followed “rigid time-based curricula” that lacked flexibility to accommodate students’ outside lives. Students were expected to work while sick, and faced “blackout” days when they were not allowed to request time off. The authors contend that this rigidity is harmful to those who are “already disadvantaged due to financial, health, or social factors,” and recommend that medical schools continue the flexibility that the pandemic necessitated. The authors also say that schools should move to “individualized and flexible competency-based curricula” and/or allow students to make up missed mandatory activities.

Addressing Racialized Trauma: The pandemic provided a clear view of the disparities in healthcare and criminal justice, and created a period of trauma for students, particularly those identifying as Asian-American, Black, or Brown. The authors recommend that schools take a proactive approach to acknowledging current events and injustices in a timely and empathetic manner, noting that this should not just come from diversity offices, but by medical school leaders. 

Empowering Medical Student Activism: During the pandemic medical schools spoke out on structural racism, which amplified activism among medical students. Racially minoritized students took a larger role in this activism. This may have harmed racial minorities compared to non-minorities by taking away time to study or enhance their medical CVs in order to do critical activism work. The authors recommend that medical schools take more tangible action to promote diversity, such as increasing funding for DEI efforts, changing institutional policies to promote internal equity, and creating relationships with expert consultants or community leaders. The authors say that schools should also ensure, to the extent possible, that students engaging in activism are not harmed by spending time on these efforts. Additionally, schools should create strategic plans to improve on DEI measures with clear short-term, incremental, and long-term goals.

National Health Service Corps Demands Additional Flexibility for Participants due to Center Closures in Pandemic-era

The National Health Service Corps is a federal program with a mandate to improve access to healthcare in underserved areas. The program provides incentives to physicians—and other medical workers including dentists, nurse practitioners, and physician assistants—to work in designated Health Professional Shortage Areas (HPSA) in exchange for scholarship or loan repayment funds.

There are three programs specific to physicians: 

1. Federal Scholarship Program: Full-time students who are U.S. citizens and complete a primary care residency are eligible to receive a scholarship for tuition and school-related expenses as well as a (taxable) stipend. For each year of scholarship, students are expected to serve a year working as a physician at an HPSA; there is a minimum of two-years full time service (or four years part-time) with a maximum of four years of scholarship. 

2. Federal Loan Repayment Program: If employed by NHSC-approved sites, primary care physicians can apply to receive loan repayment, including loans for tuition and living expenses for both their medical school and undergraduate education. Within this program, there are three tracks: general, substance-abuse workforce, and rural community. 

3. State Loan Repayment Programs: A state-tailored version of the program, with modifications on program eligibility and service requirements based on specific state-wide needs. 

The programs are competitive, with about ten percent of applicants receiving federal scholarships and entry into the loan repayment programs. However, medical students should carefully consider the contractual agreements when committing to the program. The Student Doctor Network describes the pros and cons of the program. The pros, of course, come in the form of loan repayment and scholarship, which for medical school, can provide a significant sum. The cons, however, are in the restrictive nature of the program. For physicians, scholarship recipients are locked into primary care and fellowships within primary care, which can be limited. Participants also need to be open to relocation throughout the United States, as the NHSC has the final approval on placement. This can be particularly onerous for medical providers with family responsibilities or ties to a specific geographic location. Finally, there are significant financial consequences for breaking the contract.  

The pandemic magnified the restrictive nature of the program and need for participant adaptability. Last week, the Wall Street Journal ran an article profiling several program participants who experienced center closures and resulting job loss. Upon losing their positions, they had 90 days to find a new job; in the cases profiled, the participants needed to relocate in order to find a qualifying placement and when they were unable to do so, they described significant consequences. They had to repay the money they’d received. And those who violated their contracts were charged heavy monetary fines. In one case, a dental hygienist owed a fee that was more than five times the original loan repayment. In all of the cases, the participants described obstacles that made it difficult, if not impossible, to find a qualifying role to continue their service, as well as the financial devastation that would come from repaying the loans with the penalty. 

So, is it worth it? The Student Doctor Network says, “It depends. Once you’re a physician there will be many opportunities to pay off your debt. You can choose a better paid position or find one that offers loan repayment. How committed are you to public service? To primary care? How expensive is your medical school? Like many programs with financial incentives, it is important to believe in the mission before you sign the dotted line.”

Medical Community Lauds Addition of Public Health Priorities to Methodology of U.S. News’ Medical Rankings

In response to criticism from the medical community, the U.S. News & World Report updated the methodology behind their 2022 Best Medical Schools in Primary Care ranking. A recent JAMA Viewpoint article entitled, “Increasing Transparency for Medical School Primary Care Rankings—Moving From a Beauty Contest to a Talent Show“ by Robert L. Phillips Jr, MD, MSPH, Andrew W. Bazemore, MD, MPH, and John M. Westfall, MD, MPH described the updates: “The rankings were modified in 2021 such that 30% of the score is now based on graduates practicing primary care after their residency training, rather than those entering primary care training. Initial residency comprises 10% of the score, which still overestimates primary care, but this measure has been reduced from its previous weighting of 30%. The remaining score (60%) is still largely based on reputation, which is assessed by (1) surveys of medical school deans, internal medicine chairs, or admissions directors (15%); (2) survey of primary care residency directors (15%); (3) student selectivity (median Medical College Admission Test score, 9.75%; median undergraduate grade point average, 4.5%; acceptance rate, 0.75%); and (4) faculty to student ratio (15%).” The authors call the updates to the methodology “a step in the right direction,” although they continue to express that the reputation portion of the score is subjective and self-perpetuating. 

More important than the methodology update, the authors say, is U.S. News's addition of four new data-based rankings. The newly added rankings include: 1) graduates practicing primary care; 2) most diverse medical schools; 3) graduates practicing in medically underserved areas; and 4) graduates practicing patient care in rural areas. These rankings were created with the Robert Graham Center, a division of the American Academy of Family Physicians, and were defined to measure medical schools’ performance on key health care issues. The graduate-based rankings use data collected five-to-seven years after a physician’s training, making them more reflective of student outcomes and better able to showcase the public health contributions of schools that are hidden within the broader rankings. For example, the authors point to the disparity seen in the Harvard Medical School rankings; the medical school, ranked 8th for Best Primary Care, ranks 141st for graduates practicing in primary care fields. Conversely, the Pacific Northwest University of Health Sciences, which is unranked in the primary care ranking, ranks second for graduates practicing in primary care fields, second for graduates working in medically underserved communities, and seventeenth for graduates working in rural areas.  

One of the article’s authors, Dr. Phillips, speaking with the AMA, notes that students should understand the large role that reputation plays in the mainstream rankings and should proceed with caution when using the rankings to inform their medical school options. “Students should be careful in using medical school rankings to inform their choices as many rankings are opinion-driven.” Rather, he recommended that students consider the more objective, data-driven rankings based on where and what graduates end up practicing. “We also hope that the new ranking heralds continued improvement of the information that help students make career decisions. 

On a wider-scale, the authors call out the importance of the four new rankings in providing transparency into how schools contribute to key social outcomes, for policy decisions by both states and medical schools themselves. “These outcome measures should help medical schools to assess fidelity to their missions and alter admissions, curriculum, and training settings if different outcomes are desired.”

Biden Administration Remains Under Pressure to Move Forward with Student Debt Cancellation

On May 1, 2022, which is just three months away, federal student loan payments will resume. This comes after a two-year period during which borrowers could choose whether or not they would make payments. As the date nears, the Biden administration is under pressure to make good on campaign promises to reduce student debt for millions of Americans with federal loans. Last week, 85 Democratic members of Congress sent the President a letter urging him to, “...direct the Department of Education to publicly release the memo outlining your legal authority to broadly cancel federal student loan debt and immediately cancel up to $50,000 of student loan debt per borrower.”

But it is still unclear how President Biden will move forward. During his campaign, he promised to forgive up to $10,000 per student loan borrower, but he has since expressed hesitancy to extend loan forgiveness to those attending elite schools or who obtained professional graduate degrees, and have strong repayment prospects. In a press conference last month, President Biden declined to comment on a question about student loan forgiveness. 

An article in the Wall Street Journal speculates that the Biden Administration may opt to forego blanket debt forgiveness for an alternative path, “...by starting a regulatory process, complete with input from stakeholders, to set up a debt-forgiveness program that targets people most in need.” This path may allow the administration to avoid a potential Supreme Court battle that an Executive Action may spur.

In the meantime, the administration has moved forward with more targeted loan-relief initiatives, such as a revamp of the long-standing Public Service Loan Forgiveness (PSLF) program. This would allow those who have worked for a public or nonprofit organization, and also made monthly payments for a ten-year period (120 payments) to have their loans forgiven. A revamp is exciting for current business, medical, and law students who wish to go into public service, and necessary. The original program, which dates back to 2007, burdened participants with bureaucratic hurdles, and only provided benefits to a small percentage, about 16,000 out of 1.3 million. 

Pre-Med Students Face Stress as Clinical Experiences Become Harder to Find

The stress of applying to medical school has always been significant. A Kaplan survey of 400 pre-med students, taken in early 2020, found that 37 percent “seriously considered” changing their plans for a medical career due to stress. Just over a quarter (26 percent) said that they experience stress “pretty much always,” and another 45 percent said “frequently.” Over half (57 percent) said that self-medicating with alcohol or drugs is common for them as they work to grapple with the demands. 

And experts say that the pandemic is only increasing these stressors. “I don’t think we can underestimate how COVID-19 is impacting the mental health of the entire population, never mind students who are preparing to apply to medical school,” said Carol A. Terregino, MD, and the Senior Associate Dean for Education and Academic Affairs at Rutgers Robert Wood Johnson Medical School. “There are fewer opportunities to engage in the humanistic activities, to shadow and volunteer to demonstrate one’s passion for medicine because of the pandemic and more time to focus on metrics and study for the MCAT (Medical College Admission Test). And that isn’t necessarily a good thing.”

This sentiment was echoed in a Yale News interview with pre-medical students. Students spoke of their experiences with the closures and re-openings of “wet labs,” with seniors claiming to be overlooked in favor of younger students who could commit to multiple years of research. Students also reported difficulties finding opportunities to shadow doctors, or volunteer at local hospitals. “If you’re trying to volunteer at the New Haven Hospital or the HAVEN Free Clinic, it’s hard to do so because of COVID restrictions,” Courtney Li, pre-med class of 2024, explained. “There was definitely a time period where they weren’t accepting volunteers.”

In response, Dr. Terregino provides a calming perspective to applicants. “Medicine is stressful. Getting ready for medical school is stressful. But I’d offer that one can temper their stress knowing it’s more than just grades and MCAT scores that admissions committees are looking for, and there is a full understanding of the limitations on experiences placed by the pandemic. Personal development also counts.”

So, what should pre-medical students do? 

As limitations exist, so do opportunities. Showcase your adaptability by making the best of challenging times. We recommend considering the following experiences if you are not able to find in-person shadowing or clinical roles.

• Contact current or retired physicians in your network, or access your university’s alumni network, to interview them and learn more about their specialties, experience, and advice for aspiring physicians.

• Leverage your university network, including current and retired professors and alumni, to look for in-person or virtual research opportunities.

• Pursue virtual shadowing opportunities.

• Engage in volunteer work to demonstrate your commitment to serving others and working with diverse populations.

• Consider study abroad and summer programs that provide shadowing or clinical experiences.

Continuing to pursue learning and development opportunities, even in less-than-ideal circumstances, will still prompt meaningful evolutions in your perspective and will help convince the admission committee of your commitment to the study of medicine.  

Trends in Medical Education: Online Learning

During the Harvard Medical School Office for External Education’s 2021 IMPACT Symposium, Adrienne Torda, the Associate Dean of Education and Innovation at the University of New South Wales, stated that “Digital teaching and learning are here to stay,” And most attendees, leaders in medical education agreed. The covid-19 pandemic has accelerated a movement towards online learning and technology that they expect will only grow in significance. 

Suzanne Rose, MD, MSEd, and Senior Vice Dean for Medical Education at Penn Medicine, called out technology’s impact on the delivery of medical education and patient care as one of the top five trends in medical education, noting that it can provide more interactive experiences for students that will aid in content delivery and retention. One area she is exploring is the use of shortened lectures on key topics followed by team-based learning experiences and/or small group discussions. Medhub also describes a shift to a more proactive engagement between students and technology that is “... aimed at more effectively engaging students, assessing them against measurable outcomes, and responding to individual learner needs.” 

In addition to collaborative learning, the role of Virtual Reality (VR), as well as augmented reality (AR), mixed reality (MR), and artificial intelligence (AI) are expected to grow. These tools can enhance training experiences for students as they develop an array of necessary, but difficult skills. Medhub says, “Case studies with online simulations, designed to build skills as diverse as having difficult patient conversations to making complex diagnoses, are becoming increasingly sophisticated. They are effective tools in medical education and we can expect enhancements to keep learners engaged, offer real-time feedback, identify areas of weakness, and even foster some healthy competition with performance comparisons to colleagues and leaderboards.” 

Many schools are already implementing these measures. University of Miami’s Miller School of Medicine, for example, takes advantage of AR, VR, and MR to train students on treating trauma patients. At the Gordon Center for Simulation and Innovation, students get the experience of working with stroke, heart attack, or gunshot victims, in addition to practicing cardiac procedures on Harvey, a mannequin who can simulate nearly any cardiac event. Students can wear VR headsets to get a visual of Harvey’s underlying anatomy.

While there is no doubt that many aspects of medical education must still be experienced using in-person training and experiences, technology will only grow in importance within medical education. 

Incoming 2021 Medical School Class Largest and Most Diverse Ever

The incoming 2021 class of medical students is the largest and the most diverse ever. Compared to 2020, the number of self-identified Black or African American first-year medical students grew by 21 percent, the number of Asian students increased by 8.3 percent, and Hispanic/Latino students increased by 7.1 percent. While the majority of matriculants are White (51.5 percent), there were increasing proportions of Asian (26.5 percent), Hispanic/Latino (12.7 percent) and Black or African American (11.3 percent) students. Women continue to make up the majority of the entering class at 55.5 percent, and of total medical school enrollment at 52.5 percent.

The large class comes at the end of a record-setting year for application submissions, with a 17.8 percent increase. In particular, there was an increase in the number of diverse candidates submitting applications, which was driven by a 41 percent increase in Black or African American candidates and a 25 percent increase in Hispanic/Latino applicants. Last year marked the first year that white candidates did not make up the majority of applicants at 49.7 percent; the next largest proportions of applicants were Asian (25.0 percent), Black or African American (11.7 percent) and Hispanic/Latino (11.7 percent).

The AAMC does not believe that the surge in applicants is expected to continue, and they note that the current year is trending closer to pre-pandemic levels. While there are many hypotheses regarding last year’s surge, many suggest that it was a confluence of factors including lowered application costs due to virtual interviews and expanded MCAT assistance, a dearth of available “gap year” experiences, and an increased awareness of social inequities related to health outcomes and access to health care. While many have considered the unlikely celebrity of Anthony Fauci and how he could have inspired more young people to consider medicine, there is now a real sense among the medical community that the pandemic and its key players did indeed prompt more applications, even from those initially “on the fence.”

Related blogs:

Long-Term Study of Medical School Demographics Shows “Persistent Failure” to Improve Diversity

Surge in Medical School Applications Attributed to the “Fauci Effect” and Virtual Interviews

Medical Schools Called to Increase Diversity as Pandemic Highlights Racial Disparities in Healthcare

Report Recommends Comprehensive Reforms to Improve Medical Students’ Transition to Residency

Last week the Coalition for Physician Accountability released a report recommending comprehensive reforms to improve the transition between medical school and residency. The Coalition’s Undergraduate-Graduate Medical Education Review Committee (UGRC) included 34 recommendations spanning nine themes. The report’s authors strongly encourage related stakeholders to work together to implement the recommendations in full, as together they will “create better organizational alignment, likely decrease student costs, reduce work, enhance wellness, address inequities, better prepare new physicians, and enhance patient care.”

The Charge

The UGRC’s initial charge was to address the following documented problems occurring in the transition between medical school and residency, as well as to uncover other existing issues. The report noted that the impact of these problems has grown over time resulting in significant stress to the system. 

• Disproportionate attention towards finding and filling residency positions rather than on assuring learner competence and readiness for residency training

• Unacceptable levels of stress on learners and program directors throughout the entire process

• Inattention to optimizing congruence between the goals of the applicants and the mission of the programs to ensure the highest quality health care for patients and communities

• Mistrust between medical school officials and residency program personnel

• Over reliance on licensure examination scores in the absence of valid, trustworthy measures of students’ competence and clinical abilities

• Lack of transparency to students on how residency selection actually occurs

• Increasing financial costs to students as well as opportunity costs to programs associated with skyrocketing application numbers

• The presence of individual and systemic bias throughout the transition; and 

• Inequities related to specific types of applicants such as international medical graduates

A Common Framework to Assess Students’ Clinical Skills 

At its core, the report calls for changes that promote standardized ways to evaluate and assess medical students in a meaningful and equitable way. More specifically, the report suggests that less weight should be placed on the USMLE numerical scores and the emphasis should shift to a standardized and comparable assessment of students’ performance in a clinical setting. The report recommends that medical schools and residency programs work together to define a framework and set of competencies with which to measure students as they make the transition from medical school to residency. 

The report’s recommendations also seek to increase efficiency in matching students with residency programs. The number of applications submitted per student continues to rise, as medical students fear that they will not find a placement so expand their reach. A recent AAMC article noted that the average number of residency applications per student in 2016 was 87.7 and in 2020 was 95. Among international medical student graduates, who often face a tougher time finding a spot, the average is 136. The process is a huge generator of stress for medical students, their advisors, as well as residency program directors. “This year, we received 5,800 applications for 24 positions. It’s just not possible to thoroughly review most of them,” explains Richard Alweis, MD, a UGRC committee member and associate chief medical officer for medical education at Rochester Regional Health in New York. Not surprisingly, the 2020 National Resident Matching Program Director Survey reported that just under half (49 percent) of applications receive an in-depth review. 

The UGRC’s recommendations seek to provide stakeholders involved in the application, selection, and placement processes with better information and support in an effort to reduce the number of submitted applications. Students, they contend, need access to better information to appropriately gauge their likelihood of acceptance while residency programs need better ways to cull their applicants by updating and improving technology to provide effective and equitable filters for applications. Additionally, the UGRC encourages the entire eco-system to innovate and implement pilot programs to reduce the friction associated with matching medical students to residency placements. 

Next Steps

While there is great optimism around the release of UGRC’s report, because of the comprehensive nature of the recommendations and the number of critical players involved, there is still considerable work to be done. Each of the 13 member organizations making up the Coalition is independently run; each organization will determine what recommendations they will enact and the timeline. And despite its support, the AAMC’s statement reacting to the final report emphasized a need to move with caution and carefully consider what, if any, unintended consequences may occur as a result of enacting recommendation(s). However, while the timing for change is unclear and the speed may be slow, there is unprecedented agreement within the member organizations around the need for change and improvement for students, residents, medical advisors, and resident program directors. “For the past 10 years or more, we've been stuck in the same place… The recommendations are a monumental step in breaking through that,” said Grant Lin, MD, PhD, a pediatric resident at Stanford Health Care in California and a member of the UGRC committee.

Post-MCAT Survey Shows Prospective Medical Students are Increasingly Interested in Schools that Provide Academic and Social Support

Earlier this year the AAMC released its 2020 Post-MCAT Survey results. This survey, administered annually, provides insight into the individuals who take the MCAT—their backgrounds, preparation strategies, career plans, and interests. In 2020, 39.2 percent of test-takers responded to the online survey, which equates to over 30,000 people. The survey is provided after the MCAT is submitted, but prior to the test-taker receiving results. This year’s findings show slight, but persistent shifts in the socioeconomic background of MCAT test-takers, an increased interest in the academic and social support provided by medical schools, and growing concern about the cost of applying to and attending medical school. 

Below, we provide selected findings from the latest survey:

Premedical Life and Experiences

To gauge socioeconomic status, the AAMC uses the Education Occupation (EO) indicator, which classifies test-takers as EO-1 through EO-5 based on a parent’s highest educational level and occupation. Every year since 2016, the largest proportions of MCAT test-takers have come from those categorized as EO-5 (a parent obtained a doctoral degree and/or is employed in an executive, managerial, or professional occupation) and EO-1 (a parent obtained less than a college degree and/or is employed in any occupation) at 25.4 percent and 24.1 percent, respectively. It is important to note, however, that the percentage of MCAT test-takers classified EO-1 has declined slightly each year since 2016, with a 2.6 percentage point decline over the last five years.

Most respondents, 61.9 percent, decided that they wanted to study medicine prior to entering college. And a large number reported having spent time volunteering in a healthcare setting (84.9 percent), shadowing a physician or other healthcare professional (80.9 percent), and just over half (50.7 percent) participated in a laboratory research internship program for college students. 

More respondents graduated from college prior to taking the exam (53 percent) than not (47 percent). But this percentage has shifted annually, with the exact opposite occurring in 2016 (53 percent taking the test pre-graduation and 47 percent taking it post). Most of those who had graduated did so recently: 42 percent within the last year and 31.9 percent within the last one to two years. Just 12 percent had taken five or more years between graduation and the MCAT. About 60 percent reported taking courses at a college or university in the three months prior to the MCAT, while just over a quarter (27.6 percent) said that they had not attended school in the past three months. 

MCAT Preparation Strategies

Most respondents reported that they started their preparation by reviewing the scope of topics that the MCAT covers (81.4 percent) and assessed their progress throughout their study period using practice exams (82.4). Over three-quarters of respondents created a study plan to fit their schedule (75.2 percent), identified their strengths and weaknesses using practice exams (78.3 percent), and assessed their readiness by taking a final practice exam (78.4 percent).

In terms of the concepts, most prepared by answering practice questions while studying each topic (87.8 percent), consistently reviewing content they had previously studied throughout their preparation (82.6 percent), and testing their understanding of concepts studied (80.7 percent). Slightly fewer made sure to review each answer choice in the practice questions to determine why they were correct or incorrect (74.7 percent) and mixed in their review of different topics throughout their studying (74.9 percent).

The most used resources were the Official MCAT Practice Exams (85.4 percent) and commercially published MCAT prep books (72.6 percent). In terms of utility, 73.1 percent of those who used the Official MCAT practice exams described them as “very useful,” and 61.7 percent of those who used the Official MCAT Section Bank found it “very useful”. While just 45 percent of those who used commercially published MCAT prep books called them “very useful,” another 38.4 percent labeled them “useful.”

Almost all (89.7 percent) respondents said that they prepped for the day of the test by taking a timed, online practice test with scheduled breaks to “mimic the exam day.” A large number also practiced pacing so that they could get through all the questions in each section in a timely manner (85 percent), and most (79 percent) made sure to get plenty of sleep the night before the exam. 

When asked to name their biggest challenges in preparing for the MCAT, over two-thirds said that they struggled with maintaining confidence in their ability to succeed on the MCAT (67.6 percent) and 60 percent noted their difficulty with getting through the large amount of material they needed to learn for the test. 

Career Plans and Interests

Most respondents noted that they are “very likely” to apply to an MD-granting medical program (86.8 percent), while just under one-third said that they are “very likely” to apply to a DO-granting program (32.4 percent). Both percentages have been relatively stable since 2016. 

When asked what would encourage their application to medical school, students were most likely to select: finding a school where I will feel comfortable (88.9) and a fit between my interests and a school’s mission (83.4). However, the number of students who selected availability of academic support in medical school (71 percent) and availability of social support in medical school (63.9 percent) both increased significantly from 2016 (+7.8 percentage points, +11.5 percentage points respectively).

When test-takers were asked to describe what would discourage them from applying, most students selected grades, MCAT Scores, and other academic qualifications (72.5 percent). The number of those who selected the cost of applying to medical school (53.1 percent) and the cost of medical school (68.9 percent) as deterrents has increased by 6.5 and 6.1 percentage points respectively since 2016.

For full survey results visit https://www.aamc.org/media/51241/download

Long-Term Study of Medical School Demographics Shows “Persistent Failure” to Improve Diversity

Last month, the New England Journal of Medicine published a forty-year review of medical school demographics. The analysis looked at both gender and racial/ethnic diversity within the medical student body, and found a “persistent failure to substantially improve racial and ethnic diversity.” Using data from 1978 to 2019, the study showed striking movement resulting in gender parity within medical schools, but no significant change in the proportions of underrepresented ethnic and racial groups. In particular, the number of Black men and Native American and Alaskan men and women have declined over the study period.

While American Medical Schools have often spoken of the need for a diverse physician workforce that reflects the nation’s population, the numbers produced by the multi-decade study suggest that recruiting efforts have not been effective. Black women made a moderate increase over the 40-year study period, growing from 2.2 percent of students in 1978 to 4.4 percent in 2019. But Black males actually saw a negative change. In 1978, Black men made up 3.1 percent of the student body, but just 2.9 percent in 2019. Additionally, the analysis points out the critical role that historically black universities play in educating the Black physician workforce; 15 percent of all Black men enrolled in medical school are educated at a historically Black medical school. Excluding these programs, Black men would have made up just 2.4 percent of the student body throughout the entirety of the study period. Similarly, men and women identifying as American Indian or Alaska Native or as Native Hawaiian or other Pacific Islander made up less than 1 percent of medical students. 

And progress in diversity recruiting remains slow. According to a Kaplan Medical Admissions Officers survey, just 48 percent of medical schools reported that they have a specific program in place to recruit Black students. The survey, which included 58 accredited medical schools across North America, also asked admissions officers to grade medical schools (as a whole), on their work to recruit and admit a diverse array of students and just 7 percent rewarded medical schools with an “A”. Most responses suggest that there is some, or perhaps considerable work to be done, with 41 percent choosing the grade of B, 38 percent a C, and 14 percent a D or F.

Kaplan does point out, however, that its survey results follow an optimistic report from the Association of American Medical Colleges, which shows an increase in the number of Black first-year students in 2020: 9.5 percent of first-year medical students, up from 8.8 percent the previous year. Additionally, the number of Black men entering their first year of medical school increased 12.2 percent from the previous year, and total enrollment among Black men increased by 6.2 percent. The number of American Indian or Alaska Native first year students increased by 7.8 percent.

In conversation with Stat News about the long-term demographic study, Norma Poll-Hunter, Senior Director of Equity, Diversity, and Inclusion for the AAMC expressed her mixed emotions about the current spotlight on diversity efforts, “Even the National Academies have called this an American crisis and that’s not an overstatement. This is important for the health of our nation. On one hand, we feel we’ve been saying this for how long and people are finally paying attention, at the same time, we now have so many allies and we need to leverage this moment for the long haul.”

Covid Crisis Brings Attention to the Need for Humanities in Medical School Curriculum

Over the weekend, The New York Times published an opinion piece urging medical schools to more fully integrate humanities courses and themes into their curriculum. The op-ed, written by Dr. Molly Worthen, a historian at the University of North Carolina at Chapel Hill, notes that amidst the covid crisis and student transitions to distance learning, humanities classes proliferated. Worthen discusses the usefulness of these topics when addressing questions relevant to modern healthcare. “This is the moment for champions of the medical humanities to strike. To make sense of disproportionate Covid death rates in Black and Latino communities or white evangelicals’ vaccine resistance, researchers need to consider everything from the history of redlining to theologies of God’s judgment. They cannot afford to stay in highly specialized lanes or rely solely on the familiar quantitative methods of the medical sciences.”

Dr. Worthen’s piece is just the latest among recent efforts in the healthcare community to call attention to the benefits that humanities and the arts provide within the medical curriculum. Last year, the AAMC published a report titled, The Fundamental Role of the Arts and Humanities in Medical Education. The report identified four aspects of medical training that are improved by the integration of the arts and humanities: 1) Mastering skills – improving clinical care capabilities (e.g., case presentation, critical thinking); 2) Taking perspective – showcasing the sometimes contradictory perspectives of patients and others in clinical situations; 3) Personal insight – nurturing reflection and self-understanding to promote personal wellbeing and resilience; and 4) Social advocacy – urging students to assess and improve norms when identifying and rectifying potential inequities and injustices within health care.

While the report found that most medical schools have, to varying extents, incorporated arts and humanities into their curriculums, the potential benefits have yet to be fully realized because of inconsistencies. The report details “significant variation in the content, curricula integration, teaching methods, and evaluation methods” in MD programs, and recommends ways they could both improve and assess the benefits. A few of the recommendations direct medical schools to demonstrate the linkages between humanities coursework and core physician competencies, as well as increase the collaboration between faculty, students, patients, and partners in the arts and humanities to create and implement programs.

The report also details a few of the noteworthy humanities programs currently offered in medical schools.

-          Jazz and the Art of Medicine at Penn State: This four-week elective is offered to senior-level students. Students are asked to listen to jazz music, the give and take between the lead and accompanying musicians, then relate it to standard conversations facilitated by physicians with patients. At its core, the course is about how to listen and respond, rather than simply going through the motions. Students practice these improvisational techniques in clinical visits, which allows them to improve their listening and response skills while under real time constraints. The students are also encouraged to play to their strengths and thoughtfully and proactively build their communication style as care providers. A study that compared 30 of the students to a control group showed that they displayed statistically significant and meaningful gains in adaptability and listening.

-          My Life, My Story at VA Boston Healthcare System: This program is integrated into students’ clinical work, though it does require additional time outside of standard rounds. Students work with military veterans to help them compose a personal narrative which, with the patient’s permission, is entered into their electronic medical record. This promotes the idea of patient-centered care and demonstrates to the medical students the benefits of knowing and understanding a patient as a complex human being. In qualitative assessments, students described the power of the exercise as being the “best thing they’ve done in medical school,” with many stating that they wish they knew more of their patients so intimately.

-          Program in Bioethics and Film at Stanford: Events are integrated throughout the curriculum. Students watch documentaries and films about health issues and medical care. Faculty then lead small group discussions about how gaining additional insight into people’s lives and experiences may drive a physician’s thinking when working with patients, as well as in their role as care providers in a community. These small groups also delve into topics in medical ethics, culture and perspective, and communication. While the incorporation of the film events throughout the curriculum make it difficult to measure the program’s affect, faculty say that they can see the impact on students by the quality of the discussions and student conversations afterwards.

In 2019 Richard Ratzan, MD published a piece in JAMA, How to Fix the Premedical Curriculum – Another Try, in which he described the importance of taking humanities courses as a prerequisite for understanding the human condition, and thus medicine. He recommended that medical school admissions officers boldly look for students who majored in the humanities, with science classes as options on the side. He wrote, “... No premed majors need apply; the science training will come after acceptance.” While this provocative stance has not been wholly accepted by the medical community, the many proponents of the medical humanities are gaining attention. Admissions committees are looking for more well-rounded students who understand that there are many lenses through which a physician must look to see, hear, and heal a patient. Dr. Worthen’s editorial stated it potently, “… medicine is not a science but an art that uses science as one of many tools … The scale of the Covid crisis should force both scientists and humanists to ask new questions, to realize how much they don’t know — and perhaps to learn more from one another.”

Student Loan Forgiveness Receives New Attention Under the Biden Administration

Debt is top of mind for graduate students. A Bloomberg Businessweek survey found that among 2018 graduates of prestigious MBA programs, almost half had borrowed at least $100,000 to finance the degree. The American Medical Association has long advocated for legislative action intended to ease the burden of debt on medical providers, and the American Bar Association released a report in 2020 detailing the negative impact of student debt on young lawyers’ mental health and calling for greater legislative advocacy on students’ behalf.

Late last week, when President Biden signed into law a covid relief package, he also removed a critical impediment to enacting broad-based student debt forgiveness. The bill contains a provision that allows any loan cancellation acquired between December 31, 2020 and January 1, 2026 to be excluded from taxable income. Previously, debt forgiveness (including Public Service Loan Forgiveness) was treated as additional income and taxed as such, with few exceptions. This update ensures that recipients of student debt relief are not left with large tax liabilities and are also not thrust into new tax brackets, with associated implications, due to debt cancellation.  

The counting of debt forgiveness dollars towards taxable income was a primary obstacle to broad student loan forgiveness programs. With the update now signed into law, Congressional Democrats led by Elizabeth Warren and Chuck Schumer, as well as 17 state attorneys general and consumer rights advocates are calling on President Biden to take executive action to cancel $50,000 in federal student debt per borrower. Despite this pressure, the President does not support loan forgiveness at this amount for every borrower, which he directly expressed in a CNN Town Hall last month, as it would aid people who attended elite schools or obtained professional graduate degrees and have strong repayment prospects. The Biden Administration has noted that cancelling student loans above $10,000 should be dependent on the type of loan and current income of the recipient. The President does, however, support $10,000 in blanket, federal student loan forgiveness, and he has urged Congress to legislate this action. Legislative action, he argues, will make it harder to undo. Meanwhile, he has ordered a Department of Justice review to clarify if he has the authority to cancel student loan debt via executive action. This review will be done with the White House Domestic Policy Cancel, who will also consider the best way to target loan cancellation.

While the loan forgiveness policies under consideration would not directly benefit borrowers with private or commercially held student loans, those borrowers could still benefit from the tax relief provision included in the covid relief bill. Marketwatch notes that it may help borrowers benefit from current loan relief options provided by public or private lenders as a response to the pandemic.

In an interview on student debt with the AMA, Alex Macielak, who works in student-loan refinancing, urged students to pay attention to the political discourse, “There’s a new administration. Student-loan debt is a hot topic, ... There’s been talk about forgiving loans for some people. However, how much, who would be eligible, and other important details are still in doubt. So, monitor the legislation and debate, because student loans are consistently evolving.”

AAMC Physician Workforce Report Shows an Increasing Number of Women, Physicians Nearing Retirement, and Doctors of Osteopathic Medicine

The proportion of women within the active physician workforce continues to increase, as does the proportion of those nearing retirement age and those with a Doctor of Osteopathic Medicine (DO) degree.  Late last month the Association of American Medical Colleges (AAMC) released its 2020 Physician Specialty Report, which provides demographic and specialty trends within the active physician and resident/fellow workforces. It is important to note that the data used to populate the 2020 report was reflective of the 2019 physician workforce.

Active Physicians

In 2019, over one-third of active physicians were women (36.3 percent); this percentage has been steadily rising since 2007 when women made up just over a quarter of the workforce (28.3 percent). This growth reflects the steady increase in female medical students, with women making up the majority (50.5 percent) in medical school for the first time in 2019. The report notes, however, that women still tend to remain concentrated in specialties pertaining to women and children, including pediatrics (64.3 percent), obstetrics and gynecology (58.9 percent), and pediatric hematology/oncology (55.1 percent), and have marginal representation elsewhere. Women make up less than a quarter of the physician workforce in a great number of specialties, including various surgery sub-specialties where the number ranges from 22 percent in general surgery to just 5.8 percent in orthopedic surgery. About ten percent of physicians in pulmonary disease (12.3 percent) and urology (9.5 percent) are female. There are no specialties where male physicians make up less than 35 percent of the workforce.

Just under half of the physicians were 55 and over (44.9 percent) in 2019, which is a marginal increase from 44.1 percent in 2017 but a more significant increase from 37.6 percent in 2007. Over 50 percent of the following specialties are made up of physicians aged 55 and over: preventative medicine (69.6 percent), thoracic surgery (60.1 percent), orthopedic surgery (57.1 percent), and urology (50.5 percent). Several of the specialties which are populated with older doctors also have the highest percentages of males, and conversely several of those with the lowest percentage of older doctors are among the highest in female doctors.

Another slow-moving trend is the increase in practicing physicians with a DO degree. In 2019, 8.2 percent of physicians held the DO degree, while U.S. MDs made up 66.1 percent of the workforce and international medical degrees made up 24.7 percent. This is subtle, but real growth from 2007, when 69.5 percent of physicians held a U.S. MD, 24 percent held an international medical degree, and just 6.5 percent held a DO. In one of the fastest growing specialties, sports medicine, 18.9 percent of practicing physicians were DOs in 2019.

Residents and Fellows

Among the Residents and Fellows in 2019, 45.8 percent were women, like the 2017 figure (45.6 percent), and up slightly from 44.6 percent in 2007. As seen in the physician workforce, female residents/fellows tend to pursue the care of women and children in high percentages, with obstetrics and gynecology (83.8 percent), neonatal-perinatal medicine (74.9 percent), and pediatrics coming in at the top (72.4 percent). However, large percentages of women are also pursuing specialties in endocrinology (70.8 percent), allergy/immunology (68.2 percent), and geriatrics (67.8 percent).

Just as the percentage of DO graduates increased within the active physician workforce, it was also more prominent within the resident/fellow population. In 2019, 15.7 percent of the resident/fellow workforce had a DO degree, an increase from 12.5 percent in 2017 and 6.4 percent in 2007. The percentage of U.S. MDs showed a relative decline over the same period, with 61.1 percent of the 2019 population compared to 65.9 percent in 2007; similarly, international medical school graduates declined from 27.4 percent of the resident/fellow population in 2007 to 23.1 percent in 2019.

Surge in Medical School Applications Attributed to the “Fauci Effect” and Virtual Interviews

In September we shared that applications to medical school had risen significantly compared to the same period last year, with both the American Association of Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM) reporting double-digit increases. Last week, MedPage Today confirmed that the upward trend in applications has held throughout the application season with AAMC applications, now closed, up 18 percent over the previous cycle and AACOM schools up 19 percent over the same period last year and up 7 percent over last year’s total with two months remaining in the admissions cycle.

The increase in application volume is significantly larger than recent annual increases (less than 6 percent), which suggests this year’s cycle will be more competitive. Geoffrey Young, PhD, AAMC's Senior Director of Student Affairs and Programs, estimated that just 18 percent of applicants will be accepted to AAMC schools this year. Young, along with Jayme Bograd, AACOM's Director of Application Services, Recruitment, and Student Affairs, via MedPage Today, also suggest that the large number of applicants could have an impact on future application cycles. Noting that this cycle included a similar percentage of re-applicants to previous years, both Young and Bograd agree that, if the rate holds, next year may also bring a larger number of applicants.

Medical school admissions officers have attributed this year’s application uptick to the “Fauci Effect.” Kristen Goodell, Associate Dean of Admissions at the Boston University School of Medicine, which reported a staggering 27 percent increase in applications, told NPR last month that "It may have a lot to do with the fact that people look at Anthony Fauci, look at the doctors in their community and say, 'You know, that is amazing. This is a way for me to make a difference.'"

Young, however, questions the “Fauci Effect,” pointing out that competitive medical school applicants typically spend years amassing a portfolio of educational and extracurricular experiences, rather than making an impulse decision to submit. And Bograd points out that the average age of applicants is the same this year (23.9) as it was last year, suggesting that it was not simply due to applicants opting out of a gap year. Rather, MedPage’s sources, including Young and Bograd, look to a variety of anecdotal factors that may have contributed to this year’s larger number of applicants. Both AAMC and AACOM schools use of virtual interviews significantly reduced the cost burden on applicants. Relatedly, not having to travel for interviews may have allowed applicants to apply to a wider range of schools. Additionally, osteopathic schools have increased program awareness efforts with AACOM, hosting more open houses than usual, virtually, and increasing scholarship funds. And a new DO school in Utah is accepting applications for its first class, while a few other schools have been able to expand their class sizes.

Medical Schools Called to Increase Diversity as Pandemic Highlights Racial Disparities in Healthcare

Glaring disparities in health outcomes by race, of those individuals diagnosed with COVID-19, have prompted providers and administrators to look at how structural racism has taken root within health education, training, and practice.

Late last month, The Atlantic published an article, Five Ways the Health-Care System Can Stop Amplifying Racism. While the article describes a complex system, including the inner-workings of hospitals, government, and insurance companies, it directly advocates for medical schools, and other provider training programs, to increase diversity in their student bodies and create a curriculum that addresses existing bias and racism, common in medical practice.

Medical schools have long sought to increase diversity, as diversity in providers means significant improvement in patient outcomes—A study out of Oakland, CA showed black doctors’ involvement with black patients increased preventive care and reduced the cardiovascular mortality gap between black and white men by 19 percent. Another study of black newborns in Florida showed that the newborns treated by black physicians had a mortality rate that was half that of babies cared for by non-black physicians.

But the number of minorities in medical school has remained low. A congressional report released last month by Democrats on the Senate Committee on Health, Education, Labor, and Pensions, reported that as of 2019, only 5.8 percent of physicians identified as Hispanic, 5 percent as Black or African American, 0.3 percent as American Indian or Alaskan Native, and 0.1 percent as Native Hawaiian or Other Pacific Islander. Further, among 2019 medical school graduates, 5.3 percent were Hispanic or Latino, 6.2 percent were Black, 0.2 percent were American Indian or Alaskan Native, and 0.1 percent were Native Hawaiian or Other Pacific Islander.

Why? Perhaps it is because there are barriers to medical education: substantial costs, the time and attention required to prep for and take the MCAT, apply to medical schools, travel to interviews, as well as a hostile learning environment. A report released early this year found that underrepresented minorities, including Hispanic, Black, and Native American students, were more likely to experience bullying or harassment during medical training than white students at 38 percent and 24 percent respectively.

Providing medical students with a curriculum that exposes bias and the roots of structural racism is vital. The Atlantic article points out that, “To this day, medical textbooks still depict mostly white skin tones. Many medical students hold empirically false beliefs about race-based physiological differences—including the notion that black patients have a higher tolerance for pain than white patients. These beliefs affect the kind of decisions that doctors make.” 

While people can change over time, schools must proactively work to diminish racism in future doctors. This summer, a team of professors at Yale Medical School published an article in the Journal of General Internal Medicine that proposed schools seek to filter out racist applicants and withhold admittance. While acknowledging the difficulty of evaluating racist attitudes, the professors suggest using additional essays, interview scenarios, and evaluative questionnaires to adequately provide admissions teams insight into where an applicant falls on a “continuum of racial attitudes.”

Medical School Enrollment Growth Limited by Space Constraints in Clinical Training and Residency Programs

Last month, MedPage Today reported that applications to medical school have risen significantly compared to the same period last year, according to both the American Association of Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM). AAMC reported a year-over-year increase of 14 percent in early August, and AACOM reported an uptick of 17.7 percent as of mid-August.

Sources speaking to MedPage Today pointed to the pandemic as a reason for the spike, suggesting that the current high-profile nature of medical personnel may be inspiring applications to medical school. Other applicants may be taking advantage of idle time to submit their applications early, while some may be seeking alternative paths to mitigate economic uncertainty. Geoffrey Young, AAMC’s Senior Director of Student Affairs and Programs, told MedPage that the early indicators may not necessarily indicate a more competitive year, noting that the pandemic has created “an unconventional time.”

While both AAMC and AACOM schools are expanding their capacity where possible, both note that their growth is limited due to a lack of corresponding residency spots. The AAMC has launched a few new schools, which has increased overall enrollment, and remains optimistic that many schools will be able to make incremental increases in class size. Larger updates to class sizes, however, would have to be approved by the accrediting agency. Osteopathic school enrollments are growing faster, with a 6.6 percent increase approved for the upcoming year by the accrediting agency, up from a 5.6 percent increase the year before.

This capacity constraint suggests that many qualified candidates may not find a place in medical school, despite a national need to grow the physician workforce. Results released last week from the AAMC Annual Survey also focus on the significance of the clinical experience constraint. In the survey, which was administered in November 2019 to 154 medical schools, school leaders voiced apprehension about the number of residency positions and clinical training sites available to students.

Just under half of the schools reported “major or moderate” concern about their students finding post-graduate residency positions of their choice. While medical school enrollment has seen significant growth over the last two decades, an increase of 33 percent since 2002, residency availability has grown much more slowly. Federal support for Graduate Medical Education (GME) provided through Medicaid, has been capped for the last two decades, effectively leaving funding for GME at teaching hospitals at 1996 levels. The National Resident Matching Program reports that this year 40,084 MD and DO graduates applied for only 37,256 residency positions though the Main Residency Match.

In addition to concerns about residency, a large majority of medical school leaders reported concern over the availability of clinical training sites for students. As demand increases for clinical experiences from other medical trainees, including nurse practitioners, physician assistants, and DO programs, AAMC medical schools are feeling more stretched to meet their students’ needs. Most of the survey respondents reported concern about clinical training sites and qualified primary care preceptors, 84 and 86 percent respectively, and just under three-fourths, 71 percent, mentioned concern about students having access to qualified specialty preceptors.

Early MCAT Registration Numbers Show Significant Interest in Medical School

The AAMC announced a positive outlook for future medical school classes. When the MCAT registration opened in early May, after having been closed in March and April due to stay-at-home orders, 62,000 people registered online. This is a significant increase from the typical 10,000 to 12,000 on the opening day of registration. Similarly, registration for the American Medical College Application Service in early March showed an increase of 50 percent (in the number of applications started in the same period last year) in the first three days. While not all these prospective students will submit applications, it does provide reason for optimism about the future.

President and CEO of the AAMC, David Skorton, MD, said, "We're very encouraged by students' strong interest in registering for the MCAT exam. We're starting to see hints of strong interest in people entering the field overall, even though it's quite early in the medical school application process. It is a great sign if this preliminary trend continues, because our country needs more doctors."

Medical Schools Plan to Resume Clinical Learning Experiences

In May, the AAMC provided an update on medical schools’ plans to resume operations.

For medical students working in clinical care, most schools plan to resume work this summer.  As of early May, 103 of 155 total schools had reported their plans to the AAMC; 15 percent planned to restore students’ clinical care work by the end of May, 55 percent (cumulative) by the end of June, and 77 percent (cumulative) by the end of July. An additional 15 percent were still finalizing plans.

The AAMC noted the delicate balance necessary for returning students to clinical care. Patient safety and containing COVID-19 must be parallel goals alongside allowing students access to the patient-centered learning hours they need for a timely graduation. Medical schools are also struggling to create meaningful learning opportunities due to the diminished capacity of many supervising physicians to teach and the fact that routine surgeries and visits have been limited or restricted.

According to an article published in Crain’s Health Care Forum over the weekend, during this period, many schools have front-loaded virtual course work. The article also mentioned that some schools, such as the Cleveland Clinic Lerner College of Medicine, were able to allow students’ access to patients using virtual clinics and virtual hospital rotations.

As many students prepare to return to clinical care, obstacles will remain. Many schools and hospitals are not going to allow students to work directly with confirmed or suspected COVID-19 patients and some hospitals are limiting the number of people who can enter a patient’s room simultaneously. This suggests that training will continue to require creativity and a dependence on technology, with schools working with state boards and accrediting bodies to determine what will be approved.