If you are a premedical student looking to supplement your learning and enhance your medical school application this summer, check out the Student Doctor Network (SDN) activity-finder. The activity-finder allows you to sort through summer or next-term experiences, organized into the following categories: medical/clinical work experiences, volunteer/community service experiences, research experiences, and shadowing experiences. Then it provides a list of organizations and resources for you to consider by location.
Trends in Medicine: Shortening the Preclinical Timeline
American medical schools have traditionally followed a similar structure: two years of preclinical work followed by two years of clinical rotations. But there is an emerging trend within medical education, which accelerates preclinical studies in order to allow students more time to gain clinical experiences. According to the Liaison Committee on Medical Education, during the 2019-2020 academic year, six percent of medical schools ended pre-clinicals after one year, 29 percent ended them after 1.5 years, and 56 percent retained the traditional two year structure.
Kim Lomis, MD, and Vice President for Undergraduate Medical Education Innovations at the American Medical Association, explains that the reasoning for the curriculum update is so that students are better able to contextualize learning within patient care. “Proponents argue that learners are able to better anchor their learning of foundational sciences in a meaningful context, fostering professional identity formation as well as knowledge base,” she said. Early adopters include the elite medical schools at Harvard, Duke, Vanderbilt, and NYU Grossman. Each of these schools now condense preclinical learning into the first year, with students beginning clinical clerkships at the start of their second year.
Rutgers Robert Wood Johnson Medical School recently launched its updated curriculum, which starts the clerkship after 18 months. Carol A. Terregino, MD, and Senior Associate Dean for Education and Academic Affairs at Rutgers, notes that the curriculum change is beneficial because it puts an emphasis on “knowledge for practice.”
“Anything that is going to increase students’ clinical knowledge and ability to apply that knowledge to clinical practice is going to make students stronger as future physicians,” she said. She also noted the presence of unknowns related to the recent pass-fail update of the USMLE Step One exam, which could potentially increase the importance of the Step Two exam. “To make sure my students are able to do well and prepare for the licensing exam, I want a longer launching pad to get them there,” she said.
Others say that looking just at “preclinical” and “clinical” years oversimplifies medical education. Students at Ohio University Heritage College of Osteopathic Medicine, for example, follow the traditional two and two calendar, but are exposed to clinical experiences through observations and interactions during the first two preclinical years. “Distilling a college’s program to the length of time in preclinical or clinical curriculum misses all the nuances of what each college does to prepare its students. We emphasize patient-centered care from the first day of medical school, making our students well-rounded when they engage in their clinical rotations,” said Jody M. Gerome, DO, and Heritage College’s Senior Associate Dean for Medical Education.
Related Blog: U.S. Medical Licensing Examination’s (USMLE) Step One Moves to Pass-Fail Scoring
U.S. Medical Licensing Examination’s (USMLE) Step One Moves to Pass-Fail Scoring
Last month, for the first time, the U.S. Medical Licensing Examination (USMLE) administered the Step One exam to second-year medical students in a pass-fail format. The USMLE finalized the decision to replace the scoring last December, explaining that the exam was intended for use as a benchmark and not to differentiate between students. They also acknowledged that students were prioritizing Step One preparation “at the expense of other curricula and their own well-being.”
Priya Jaisinghani, MD, an endocrinology fellow at New York-Presbyterian Weill Cornell Medical Center, called the move, “a step in the right direction” in an interview with MedPage Today. She suggested that early medical students can now re-prioritize critical medical skills as opposed to burying themselves in test preparation. "There was so much onus on the exam. Now [students can] shift focus to experiences, organizations, community health, and research," she said. DO students may also feel some relief at the update. While they are required to take the COMLEX, many elect to take the Step One in order to increase the competitiveness of their residency applications.
Others suggest that the move will negatively affect some students seeking to differentiate themselves as applicants to highly-competitive residencies. While unofficial, many specialties are known to have score cut-offs for residency applicants. Among the 2019-2020 first-year residents, Step One scores among thoracic surgery, orthopedic surgery, and otolaryngology averaged 247.3, 246.3, and 246.8, respectively. Residents in emergency medicine (230.9), family medicine (215.5), and internal medicine pediatrics (235.5) received lower scores on average. A 2021 survey of orthopedic surgery program directors confirms this point, with 68 percent calling the Step One score “extremely or very important” for applicant interview selection.
According to USMLE, removing the scores will encourage programs to review candidates more holistically. Practically, however, it is unclear what that may look like in the near term. Some students, speaking to Medpage Today, suggested that letters of recommendation and school rankings may play a more outsized role in residency considerations. "It makes it harder if you are coming from smaller institutions. It becomes more about who you know and who's making phone calls for you. Students with great medical pedigrees may have more advantages,” Lena Josifi, MD, a fourth-year orthopedic surgery resident at Southern Illinois University, said.
A survey of orthopedic surgery program directors confirms Josifi’s hunch. Over one-third (37.7 percent) agree that the changes to Step One scoring would “probably” or “definitely” decrease the likelihood that applicants from lower-ranked medical schools would be selected for interviews. The majority, 81 percent, also agreed that Step Two results will grow in importance.
The Medical School Admissions Process is Long and Stressful. How are you Coping?
Earlier this month, Dr. Anne Thorndike, a physician in internal medicine at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School, wrote that physician burnout starts with the medical school admissions process, which takes almost twice the length of time as other graduate admissions processes. In an opinion piece for STAT, an online health, medicine, and scientific discovery publication, she called for a shortened admissions timeline for medical school applicants and says the current process is time-consuming, expensive, highly-competitive, and intensely stressful.
Referencing a plethora of studies, she goes on to describe the stress that medical school applicants face prior to even beginning their professional journey. A 2012 study showed higher emotional exhaustion, a symptom of burnout, in pre-medical students compared to non-premedical students. In another study, 33 Black and Hispanic medical students interviewed from across the country described medical school admissions as “very negative” because it was overwhelming and required an “extensive investment of time.” A 2020 online survey found that 73 percent of 556 medical school applicants had depression or anxiety symptoms, with half reporting uncertainty related to the application timeline.
So, how can you manage effectively this daunting process as an applicant? We encourage you to explore and refine various coping mechanisms—exercise, mindfulness, talk therapy, and/or outside adventure activities—that work for you. Taking this step will be just as critical to any application prep course you will take. And you will certainly carry with you these practices into your future career in medicine.
A recent article in the Washington Post covers the physical effects of stress and the practices that may mitigate its impact. Ahmed Tawakol, Director of Nuclear Cardiology at the Massachusetts General Hospital and Harvard Medical School, recommends regular exercise, and high-quality sleep which “...can reduce stress activity in the brain, systemic inflammation, and your risk of developing cardiovascular disease.” Others interviewed point to the power of deep-breathing exercises, muscle relaxation techniques, meditation, and/or yoga, which can actually decrease your body’s reactivity to stress.
As you prepare for medical school, consider carefully how your habits may help or hinder you. Then you can work to integrate stress-reducing practices and positive choices into your daily life.
Related Blogs:
Pre-Med Students Face Stress as Clinical Experiences Become Harder to Find
Narrative Medicine Helps Physicians Gain Empathy, Make Connections, and Accept Difficult Experiences
When to Use the AMCAS Disadvantaged Applicant Status
Applicants to medical school may apply as a disadvantaged candidate through the AMCAS portal. If they opt in, they are allotted 1,325 characters to respond to an additional essay prompt: "Do you wish to be considered a disadvantaged applicant by any of your designated medical schools that may consider such factors (social, economic or educational)?"
When determining if this designation is appropriate you will want to consider the following:
Does my disadvantage fall into one of these categories: economic, social, or educational? For example, did you attend an underfunded/underperforming high school that left you struggling to adjust to college (with associated impacts on your GPA)? Or were your individual or family assets below specified thresholds, which qualified you for state or federal assistance programs?
Did my disadvantage change my application to medical school in a way that necessitates additional context for the admissions committee? For example, did you grow up in a rural area that is medically underserved, which impacted your ability to obtain clinical experiences?
If you feel that you’ve experienced a situation that merits the disadvantaged designation, use this essay to provide the admissions committee necessary context as they review your application. We recommend that you spend about 20 percent of your writing on the situation itself, using fact-based (rather than emotional) language. You want to clearly convey the reality of the situation and the direct impacts of your experience on your medical school application. The remaining 80 percent of your essay should focus on the actions that you’ve taken to combat the adversity you’ve faced, and what you’ve learned from it. And be sure to explain how your learnings will impact you as a medical student and physician. Are you more resourceful, hardworking, empathic, and adaptable as a result?
New Study Finds that Affirmative Action Bans Result in Fewer Students from Underrepresented Groups in Public Medical Schools
A study published last week in the peer-reviewed journal, Annals of Internal Medicine, found that affirmative action bans negatively impacted enrollment of underrepresented students in public medical schools. The study showed that in states which enacted bans, five years later, the proportion of underrepresented racial and ethnic minority students fell by more than one-third.
The study, which was led by Dan Ly, MD, and an assistant professor of medicine at UCLA’s David Geffen School of Medicine, examined matriculants from 53 medical schools at public universities from 1985 through 2019. The researchers focused on students from underrepresented racial and ethnic groups including: Black, Hispanic, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander. Of the 53 medical schools, 32 were located within a state without an affirmative action ban and 21 were within a state with an affirmative action ban (Arizona, California, Florida, Michigan, Nebraska, Oklahoma, Texas, and Washington). The bans were enacted between 1997 and 2013, and Texas’s ban was reversed in 2003. On average, in the year prior to a state implementing a ban, underrepresented students made up 14.8 percent of the public medical school enrollment. Five years after the states’ bans, underrepresented student enrollment had fallen by an average of 37 percent.
Dr. Ly describes the importance of the findings. "We know that a more diverse physician workforce leads to better care for racial- and ethnic-minority patients," he said. "Our research shows that bans on affirmative action, like the one California passed in 1996, have had a devastating impact on the diversity of our medical student body and physician pipeline."
The authors note that the study did have limitations, which included the indirect effects of affirmative action on undergraduate admissions, the impact that public discussion of affirmative action may have had on medical school enrollment prior to the bans, and the possibility that some students may not have identified with the racial and ethnic groups defined by the study. Additionally, the study authors did not confirm if any schools in states without bans opted not to incorporate race or ethnicity in admissions decisions. However, the authors are optimistic that the study will provide policy-makers with a clearer understanding of the lag in diversifying medical student and physician populations, as well as informing them of the impact of affirmative action bans.
A co-author of the study, Utibe Essien, MD, and an assistant professor of medicine at the University of Pittsburgh, notes that the findings are particularly poignant at this juncture. "As our country has spent the last two years weaving through the twin pandemics of racial health disparities amplified by COVID-19 and structural racism at large, our findings are critically important," he said. "As we observed, affirmative action bans have resulted in a loss of underrepresented physicians, who could have been at the front lines of caring for vulnerable populations throughout the pandemic and helping to alleviate disparities in care.”
Related Blog: Medical Schools Limited on Use of Race in Admissions Decisions but Still Seek to Promote Diversity
New Physicians that Train in Surgery or Identify as a Sexual Minority are More Likely to Struggle with Mental Health During Intern Year
The trials of residency, particularly in the first year after completing medical school, are well documented. First year residents or interns work long and demanding hours in a high stress environment, and do so on little and irregular sleep. And two new studies out of the University of Michigan, which used data from the Michigan Neuroscience Institute’s Intern Health Study, show that two groups are at higher risk for developing negative mental health outcomes during this time: surgical trainees and those who identify as a sexual minority (lesbian, gay, bisexual, or other non-heterosexual).
The first study led by Tasha Hughes, MD, MPH, and an assistant professor in the University of Michigan Department of Surgery, explored changes in surgical residents’ mental health during the intern year, and also looked at how surgical residents’ experiences compare to those of other (non-surgical) residents.
Hughes and her team found that, initially, surgical interns enter the program with lower rates of existing depression symptoms than a similar age cohort within the general population. However, after the intern year, almost one-third (32 percent) of interns screened positive for depression, based on their scores from at least one mood survey.
Among the surgical interns, some demographic groups were more likely to develop depression—females, sexual minorities, singles (those with no partner), those working the most hours on average, and those with a history of negative childhood experiences. However, even after adjusting for these demographic factors, surgical interns were more likely than other interns to develop new-onset depression, except for when work hours were taken into account. Additionally, among those who screened positive for depression, 64 percent continued to report signs of depression on a later survey.
Perhaps, equally worrisome, was that many of the surgical interns did not seek assistance. Just 26 percent of those whose scores were consistent with depression sought mental health care during their intern year. Hughes explains the importance of the findings for promoting a healthier learning environment. “Surgical training, especially in the United States, can be a period of intense stress, which we find is linked to new onset of depression,” said Hughes. “These findings suggest a need for surgical program directors, leaders, and health systems to continue to find ways to mitigate the effects of surgical training, normalize help-seeking, make mental health support easily available, and pay special attention to those with characteristics that might put them at increased risk.”
The second study, led by Tejal Patel, a student in her senior year at the University of Michigan, looked specifically at interns who started training in 2016 through 2018 and who identified as lesbian, gay, bisexual, or other non-heterosexual.
At the commencement of the intern year, the sexual minority group’s depression scores were higher than those of the heterosexual group. However, rather than remaining consistent over time, the study found that the gap increased throughout the year with larger differences in mental health occurring in the second half of the year. “These results indicate that interns who are part of sexual minority groups may experience unique workplace stressors leading to a widening disparity in mental health,” said Patel.
Early Learning Experiences in Med School Shown to Impact Burnout, Empathy, and Career Regret
Early learning experiences in medical school impact students’ burnout, exhaustion, empathy, and career regret levels at graduation. A longitudinal study, published in JAMA, finds that medical students who report experiencing mistreatment prior to their second year have higher levels of burnout and career regret two years later. And the opposite also holds true. Students with positive experiences report lower burnout levels, higher empathy, and less career regret at graduation.
The study, led by Liselotte Dyrbye, MD, MHPE, Daniel Satele, BA, and Colin West, MD, PhD, includes over 14,000 students from 140 allopathic medical schools who responded to the AAMC Medical School Year Two Questionnaire and the 2016-2018 AAMC Graduation Questionnaire.
The study findings show that just over three-quarters of students reported no mistreatment (77.1 percent) on the Year Two Questionnaire. Among the remaining 22.9 percent of students, 11.3 percent reported mistreatment in one instance, and 11.6 percent reported mistreatment in more than one instance. Within the group who experienced mistreatment more than once, the Graduation Questionnaires were more likely to indicate:
Career choice regret (6.4 percent for those who never experienced mistreatment, 7 percent for once, and 11.4 percent for more than once)
Greater exhaustion (mean scores: 12 for never, 13 for once, and 13.8 for more than once)
Higher levels of disengagement (mean scores: 5.3 for never, 5.5 for once, and 6.0 for more than once)
Among those students who reported a more positive emotional climate on the Year Two Questionnaire, the relationships were the opposite. Their Graduation Questionnaires were more likely to show:
Lower exhaustion levels (for each 1-point increase in emotional climate, there was a reduction by .05 in exhaustion)
Lower disengagement scores (for each 1-point increase in emotional climate, there was a reduction of .04 in disengagement)
Students who reported positive faculty interactions on the Year Two Questionnaire were more likely to receive higher empathy scores on the Graduation Questionnaire. And, positive interactions with other students resulted in lower instances of career regret at the conclusion of medical school.
The study authors note that medical school administrators may use these findings to craft learning environments that “mitigate burnout, decline in empathy, and career choice regret among their students.” The authors write, "Although the most effective approaches to addressing mistreatment of learners remain elusive, the frequency of mistreatment varies between educational programs, suggesting there are likely to be levers within the control of the organization that adequate commitment, leadership, infrastructure, resources, and accountability can lead to a meaningful reduction in mistreatment." The authors also suggest that schools consider strategies to reduce stress among students and promote positive learning environments, such as installing learning communities, pass/fail grading, and faculty development.
MedPage Today quoted Charles Griffith III, MD, of the University of Kentucky College of Medicine, who noted in a commentary on the study that, while the authors’ use of student-level, rather than institution-level data, limited the utility of the analysis, it may still inform interventions. "Some students in this study perceived mistreatment and did not believe the learning environment was supportive, but students from the same school believed the learning environment was indeed supportive," he wrote. "For a school considering change, based on these findings, does the school focus on making global changes to aspects of the overall learning environment, or do they identify students not supported by the current learning environment to tailor support on an individual level rather than a macro level?"
Medical Researchers Gain Patient Experience Insights via Social Media Posts
Scrolling through Twitter may feel like a casual downtime activity, but a recent Wall Street Journal article describes social media’s growing utility as a medical research tool. Increasingly, researchers are using AI and other data-culling techniques, to sift through social media comments and gather real-time, unfiltered feedback on patient experiences—from the patients themselves.
In an interview with the WSJ, Dr. Graciela Gonzalez-Hernandez, an Associate Professor at the University of Pennsylvania’s Perelman School of Medicine said, “Collecting abundant social-media data is cost-effective, does not involve burdening participants, and is available in real time.” She also points out that it may be more inclusive of populations often underrepresented in biomedical trials or cohort studies. And, most importantly, social media provides researchers direct access to unfiltered patient commentary on their experiences. “Healthcare providers report what they deem important, such that serious events are overrepresented, while bothersome side effects that may be of great importance to patients and lead to nonadherence and non-persistence are underrepresented,” Gonzalez-Hernandez said.
The article describes how researchers studying an opioid withdrawal drug have benefited from social media scans. Dr. Abeed Sarker, an Assistant Professor of Biomedical Informatics at Emory University, and his team used natural language processing algorithms to search Reddit for comments on opioid withdrawal experiences. Dr. Sarker’s team found that Reddit contributors frequently described concerns about withdrawal drugs causing “precipitated withdrawal,” or extreme withdrawal symptoms, among those who have used fentanyl. Importantly, many of these users’ comments expressed concern that their medical providers did not understand this condition. The study also found that the quantity of posts about fentanyl and withdrawal have increased over a seven-year period. These findings have played a key role in bringing to light the urgency of this issue for physicians researching withdrawal assistance drugs.
In France, a similar study took place to better understand breast cancer patients’ quality of life. The researchers used an algorithm to scan comments left on Facebook and a French online forum for breast-cancer patients. Researchers compared these insights with the European Organization for Research and Treatment of Cancer’s quality of life questionnaire to ensure it was inclusive of the most pertinent topics. The online comments brought to light two additional topics that were top of mind for patients—nonconventional treatments and patients’ relationships with their families—which will be added to future iterations of the questionnaire for formal study.
Many researchers seem intrigued by the possibility of using social media data in combination with traditional research. Su Golder, an Associate Professor at the University of York in England, is working on a medical literature review on HPV vaccines, which will incorporate Twitter and WebMD comments. “It’s important to research what the public is worried about,” Dr. Golder said. She notes that the benefits of social media data—patient perspectives and real-time information—can be meaningful, and that its shortcomings—comments that may confuse association with causation—can be overcome by combining the findings with traditional research efforts.
Social media data might also work in combination with electronic medical records to improve patient care. A recent study by Dr. Munmun De Choudhury, an Associate Professor at Georgia Tech, created an algorithm to predict psychosis relapses and re-hospitalizations using the social media posts of 50 adult and adolescent psychosis patients who suffered relapses and hospitalization, along with their medical records. The study found that in the month preceding the relapse, there were distinct changes to social media usage in the form of language patterns—words related to “anger, death, or emotional withdrawal”—and the number of posts between midnight and 5am. The algorithm was able to accurately predict about 71 percent of relapses. Dr. De Choudhury is currently working with the state medical system to determine how to incorporate the algorithm into physicians’ clinical care processes.
Medical Students Push for Climate-Related Health Courses
Emory Medical School, at the behest of its student population, has formally incorporated the health impacts of climate change into the medical school curriculum. The addition, which follows many public health programs throughout the country, makes Emory the latest elite medical school to incorporate climate-related health courses.
Emory’s decision—and the student pressure behind it—falls in line with an article published last fall in The Journal of Climate Change and Health. In the article, survey results (including responses from 600 students from 12 medical schools) showed that most medical students want to include climate change in their studies. 83.9 percent of respondents believed that climate change and its health effects should be included within the core medical school curriculum. 13 percent believed that their school currently provided adequate education on the topic. And just 6.3 percent of students said that they felt “very prepared” to discuss how climate change can affect health with a patient.
Momentum around educating students on climate change is growing within the medical community. Emory joins Johns Hopkins University, Harvard, Yale, and the University of Washington among others. Johns Hopkins created its Environmental Health Institute in 2007, and in 2017 Columbia University unveiled its Global Consortium on Climate and Health Education. Columbia’s Consortium, which develops best practices for teaching climate health, has now grown to include 47 U.S. medical schools as members, as well as more than 240 schools of medicine, nursing, public health, dentistry, and veterinary medicine globally.
Additionally, the American Medical Association has endorsed teaching medical students about the impacts of the climate on health. “All physicians, whether in training or in practice for many years, have to be able to assess for, manage, and effectively treat the health effects of climate change,” Lisa Howley, PhD and AAMC Senior Director of Strategic Initiatives and Partnerships said.
The AAMC understands that there will be some resistance to climate health’s inclusion in already packed curriculums, and have highlighted a few ways climate change has been meaningfully integrated into current medical curriculums:
At the University of Illinois College of Medicine (Urbana-Champaign), climate-related health risks have been incorporated into case scenarios to promote a physician’s consideration of the environment along with other contextual factors. The physician also learns to incorporate and consider not just medical treatment, but also environmental mitigation factors (masks, HVAC filters, etc.).
At the Icahn School of Medicine at Mount Sinai (New York City), climate information has been integrated into existing medical content for first- and second-year students. For example, slides that cover Lyme disease also include information on how climate change impacts tick habitats. The information is designed to complement existing content.
At the University of Colorado School of Medicine, an elective course for fourth-year students titled “Climate Medicine,” incorporates op-ed writing in addition to climate and health content.
At the University of California San Francisco Medical School, medical students partner with nursing and dentistry students to create the Human Health and Climate Change group to facilitate educational forums and on-campus sustainability initiatives.
Medical Student Calls for Greater Transparency in Residency Match Data
National Match Day took place on Friday, March 18, 2022. According to the National Resident Matching Program, NRMP, it was a successful day, which “realized many significant milestones” including:
Consistent or increased match rates across applicant types:
--US MD Seniors PGY-1 matched at 92.9 percent (+0.1 percentage points from 2021)
--US DO Seniors matched at 91.3 percent (+2.2)
--US citizen international medical graduates matched at 61.4 percent (+1.9)
--Non-US citizen international medical graduates matched at 58.1 percent (+3.3)
--And it was the highest match rate on record for previous year graduates, with US MD graduates matching at a rate of 50.5 percent (+2.3), and DO graduates matching at a rate of 53.6 percent (+9.3).
However, a recent article written by Nicole Mott, a student at the University of Michigan Medical School, and published in the New England Journal of Medicine, with a follow-up interview on MedPage Today contends that most current match reporting only tells part of the story. Mott is calling for the NRMP to reconsider how the match rate is calculated and to provide additional transparency into the match data.
She starts by pointing out aspects of the current reporting that can be misleading or confusing.
The published NRMP “match rate” doesn’t include all specialties and programs; it excludes ophthalmology, urology, and military training programs.
The variation in match rates by applicant type should always be called out explicitly (as seen above) in recognition of the significant variation in match rates between applicant types: MD Senior, DO Senior, IMG (citizen or non-citizen), and graduates (MD, DO). The media often just reports one overall (or applicant type) match rate, which can be misleading and create inaccurate expectations among applicants regarding the likelihood of receiving a match.
Next, she calls for a reconsideration of how the current match rate is calculated. Currently, the match rate is the proportion of “active applicants” who match into a participating residency program. However, an “active applicant” is someone who registers for the NRMP match and submits a rank order list. Mott points out that approximately eight percent of NRMP registrants withdraw or do not submit a rank order list and are thus excluded from the calculation. This includes participants who apply to programs but are not invited to interview and therefore do not submit a rank order list. This definition of active applicant likely inflates the match rate and underestimates the number of physicians who are unable to find a residency placement.
She also provides suggestions for data that, if made publicly available, would help inform medical students as they make plans for the future.
The number of applicants who register for NRMP match and don’t submit a rank order list, as well as the characteristics of this group. This would provide insight into potential inequities in the process, as well as applicant competitiveness for specialties.
The number and characteristics of unmatched physicians including those who only match into a preliminary first-year position. It would also be helpful to include information on the careers these physicians pursue and where they ended up, which could inform physician workforce planning.
Detailed match outcomes relevant to students going through the process, which could inform students pursuing a match, and also drive systemic improvements. This may include the specialty-specific matching positions on rank order lists, which could also inform decisions such as application or interview caps.
Mott notes that the proportion of MD and DO seniors matched to their top-ranked programs has “subtly declined” over the past 15 years and, during the same period, the number matched to their fourth-ranked choice or lower has increased. Additionally, she calls out the “over-congestion” in the residency application process. Applicants are now applying to more programs than ever, just as programs are receiving more applicants. She recommends a review of the data to determine if caps should be placed on the number of applications and interviews. Similarly, she calls for more transparency from residency programs in their selection criteria. Programs should be explicit in the criteria they seek in an applicant, and applicants should be more specific about their goals and geographic preferences.
Ultimately, better data, and more visibility into the match process will benefit students and residency programs, and allow each to make the best possible decisions.
Harvard Medical School and University of Washington School of Medicine Maintain Top Ranking in US News’ Ranking of Research and Primary Care Medical Schools
Among research-oriented medical schools, Harvard and NYU Grossman maintained their positions in the top two spots of the US News ranking. However, the top ten did see movement with Johns Hopkins University School of Medicine moving up into the third spot, from a tie at seventh place last year. Johns Hopkins shares the third rank, in a three-way tie, with Columbia University and University of California San Francisco. University of Pennsylvania’s Perelman School of Medicine also moved upwards, from ninth place last year to a tie at number six this year. Perelman shares the sixth rank with Duke University.
Find the complete 2023 Best Medical Schools: Research ranking.
For the primary care ranking, the top two schools maintained their places with University of Washington first, followed by the University of California San Francisco. Two new schools entered the top ten—University of California Davis moved up three spots to the eighth rank, from eleventh last year, and University of Pittsburgh had a meteoric rise into the top ten from the thirty-fourth rank last year. The school shares the tenth rank, in a three-way tie, with University of Kansas Medical Center and University of Massachusetts Chan Medical School.
Find the complete 2023 Best Medical Schools: Primary Care ranking.
Narrative Medicine Helps Physicians Gain Empathy, Make Connections, and Accept Difficult Experiences
Creative writing may not be the first course that comes to mind when you think about a pre-med or medical school curriculum. But, writing—along with other arts and humanities courses—can play a vital role in preparing medical students for life as a physician.
Rita Charon, along with a multidisciplinary group of scholars, founded the discipline of narrative medicine in 2003, in response to the increasingly bureaucratic direction of medical care. Narrative medicine’s goal is to recenter physicians on the humanity of their patients by providing tools to allow physicians to contextualize patients outside of the hospital setting and uncover ways to connect by considering a patient’s pain, stories, life, and loved ones. Charon describes narrative medicine as a “...commitment to understanding patients’ lives, caring for the caregivers, and giving voice to the suffering.”
The benefits of incorporating narrative medicine, or the study of arts and humanities into the medical curriculum are clear. In 2010, Columbia Medical Students were required to take a half-semester arts and humanities course in narrative medicine, and these students were then interviewed in focus groups about the experience. The findings, published in the Journal of Academic Medicine in 2014, were summarized: “Students’ comments articulated the known features of narrative medicine—attention, representation, and affiliation—and endorsed all three as being valuable to professional identity development. They spoke of the salience of their work in narrative medicine to medicine and medical education and its dividends of critical thinking, reflection, and pleasure.”
In addition to promoting empathy and connection, Pulitzer Prize-winning journalist Michael Vitez, Director of Narrative Medicine at Temple University’s School of Medicine, spoke to the value that writing can provide in helping students work through complex and painful experiences. He described a medical student who wrote a poem after a difficult day in her psychiatric rotation. “It helped her process her emotions and turn a really bad day into something valuable,” he said.
Narrative medicine can also bolster physicians who are struggling with symptoms of burnout. “No one was talking about clinician burnout at that time. But, as narrative medicine programs began to spread across the country, some physicians trained in its principles began to see how it can protect clinicians from feeling a sense of depersonalization and other symptoms of burnout,” Dr. Charon told Neurology Today. In the same article, Sneha Mantri, MD, MS, and Assistant Professor of Neurology at Duke University School of Medicine, described how her struggle caring for critically ill patients during residency led her to seek an MS in Narrative Medicine. In her view, the degree gave her the tools to return to medical practice and deal with the “burnout-inducing frustration of treating chronically ill patients with difficult-to-manage symptoms” and replace it with empathy for the patient’s perspective and the reminder “that knowing medical facts is just one part of caring for a patient.”
If you are a premedical or medical student with an interest in the arts and humanities, pursue it! It will likely play an invaluable role in preparing you to analyze, contextualize, and show up for patients with empathy and understanding. And as you prepare your applications for medical school, residency, or fellowship, be sure to highlight the skills that you have gained through previous humanities coursework and experiences, and the perspectives you have gained.
Examples of narrative medical texts here:
“How to Tell a Mother Her Child Is Dead,” Naomi Rosenberg, MD, New York Times
“What We Talk About When We Talk About the Code,” Lilli Schussler, JAMA Cardiology
Related blogs:
Covid Crisis Brings Attention to the Need for Humanities in Medical School Curriculum
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:
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.
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.
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.