Medical school current events

Biden Administration Works to Improve Nutrition and Health Education in Medical School Curriculums

Despite the prevalence of obesity and related diseases, including type 2 diabetes, hypertension, heart disease, cancer, and stroke in the US, there is little training on nutrition in American medical schools. 

Dr. Stephen Devries, a cardiologist and co-lead of the Nutrition Education Working Group at the Harvard School of Public Health, spoke about this gap in the medical curriculum on a recent AMA podcast. “Nutrition just hasn't been recognized as a priority in medical education, despite the fact that dietary changes are well recognized to be the leading risk factor for premature death and disability in the United States. On average, medical students spend about 19 hours over the course of four years in medical school on nutrition. But much of that is related to biochemistry and topics that are important but not directly clinically relevant for patients. So in the absence of meaningful nutrition education, what are medical students to think when they graduate, other than the fact that nutrition must not be very important in their training because they only learned about drugs and procedures?” he said. 

Due to the public health concern and the costs related to poor nutrition, government representatives are starting to speak up. From the House of Representatives to the White House, there are calls for action to improve education and outreach on nutrition and diet-related disease from medical schools to elementary schools. Earlier this year, following a congressional briefing with the Nutrition Education Working Group at the Harvard School of Public Health, Congressman McGovern (D, MA) and Congressman Burgess (R, TX) passed a bipartisan resolution in the House calling for “medical schools, residency, and fellowship programs to provide nutrition education that demonstrates the connection between diet and disease.” The resolution will encourage federal agencies to prioritize funding for medical “programs that incorporate substantive training in nutrition and diet sufficient for physicians and health professionals to meaningfully incorporate nutrition interventions and dietary referrals into medical practice.” 

In late September, the White House hosted its first Conference on Hunger, Nutrition, and Health in over 50 years where they unveiled a formal strategy to promote better nutrition and improve food security. The administration announced $8 billion in commitments, underneath five pillars, involving stakeholders from non-profits to universities to tech start-ups. The second pillar, “Integrate Nutrition and Health,” is most heavily geared towards medical students and physicians. Some of the named actions include:

  • A commitment by the American College of Lifestyle Medicine (ACLM) to make an in-kind donation of $24.1 million to improve nutrition training for medical professionals

  • A first-ever Medical Education Summit on Nutrition in Practice organized by the AAMC and ACGME to convene 150 medical education leaders

  • A signed pledge by many leading health organizations (including the National Medical Association and National Hispanic Medical Association) to take action on strengthening health professionals’ nutrition education

  • A commitment by The University of South Carolina School of Medicine Greenville to make a $4.8 million in-kind donation to assist in the implementation of its Lifestyle Medicine curriculum for interested medical schools and to provide content guidance to the National Board of Medical Examiners

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 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.”

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

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.”

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.”

Positive Learning Environments and Regular Feedback Result in Lower Levels of Depression Among Medical Residents

The impending physician shortage, coupled with the problem of physician burnout, has led to important discourse over the treatment and training of future physicians. Medical training programs are looking to improve wellbeing among medical students and residents through various avenues including reduced tuition, investments in wellbeing programs, and mental health resources. But are they doing enough? A recent op-ed published by the AAMC, by Srijan Sen, MD, PHD, suggests medical residency programs need systemic changes on top of the current efforts focused on building individuals’ resilience and wellbeing.  

Dr. Sen, along with collaborator Connie Guille, MD, analyzed data collected via the Intern Health Study to highlight the negative impacts of residency on interns’ health and propose data-based solutions for a healthier environment. The Intern Health Study, a longitudinal study that includes responses from more than 20,000 medical trainees, shows that the rate of depression increases “Five-fold within the first few months of residency” and remains higher throughout training with “about one out of four residents screening positive for depression at any given time during residency.” Dr. Sen goes on to note that beyond the questionnaire responses describing stress, there are physical indicators as well. “Telomeres, a cellular marker of aging, shorten five times as much during internship as during a typical year of life…” And, what’s more, a compromised physician is more likely to make medical errors and to provide lower-quality care to patients.

Dr. Sen references a 2019 study that reviewed over 50 internal medicine programs using residents’ feedback and information collected in national databases. The findings show variation in the depression rates between programs; more importantly, the variation showed consistency with some programs regularly registering high and others low. When Dr. Sen compared the programs, the findings showed that while the volume of hours, type of work (administrative versus patient care), and work-family conflict all impact the rates of depression, another critical component differentiating the high and low depression programs was the type of learning environment.  “A key factor among low-depression programs was residents reporting that their inpatient rotations were a positive learning experience. Another was receiving timely and appropriate feedback from faculty. Both of these factors indicate that a focus on education, and specifically directed education from faculty, makes a major difference.”

The findings are particularly pertinent given an article published last week in the NY Times by Perri Klass, MD. The article, which is in response to a recently published JAMA Pediatrics article (Walking on Eggshells With Trainees in the Clinical Learning Environment), speaks to the difficulties that many faculty members feel providing feedback to trainees. While the medical community is working hard to end the harassment and bullying of residents that typified many interns’ experiences historically, some feel the pendulum has swung too far and that they are unable to provide criticism, tough feedback, or make interns feel discomfort without retribution or poor evaluations.

Dr. Klass quotes Dr. Janet R. Serwint, professor emerita of pediatrics at Johns Hopkins, who says, “When I look back at my career and my life and how important some of that feedback was, and it was hard for the giver to give to me, I’m sure, but they did it in a respectful way… I worry that the balance is swinging in such a way that it’s all about, oh, you are wonderful.” During her time as the vice chairwoman of education and the residency program director, she said that some faculty would mention problem residents, but often they had not broached the issues directly with them. “It’s the discomfort, or the worry of retaliation and evaluation.” Furthermore, Dr. Melanie Gold, lead author of the JAMA article, goes on to say that she has also struggled with interns unwilling to experience discomfort during medical training. Her examples include a student who complained to a course director about transgender health’s inclusion in the curriculum and others who, due to religious objection, were unwilling to even observe a patient consultation. Dr. Gold went on to say that many faculty members feel ill equipped to engage in the resulting difficult conversations.

While these articles are written from differing perspectives, they describe a shared desire by residents and faculty for meaningful feedback and instruction. Given that discomfort is an inherent condition of medical training, the data would suggest that some programs are able to navigate this discomfort better than others. Dr. Sen says that “Faculty members also need to learn trainees’ specific strengths and weaknesses and then provide thoughtful, specific feedback that truly supports their learning. Programs ought to encourage faculty to invest the time necessary to support learners and reward them for doing so.”

Following this discourse is important for future medical students and interns who are applying to medical school or residency programs. Applicants can distinguish themselves by showing that they understand the role that feedback—positive and negative—plays in preparing for a medical career. Demonstrate this understanding by using interviews and essays to describe situations where negative feedback spurred improvement, learning, and connection with others despite discomfort. Just as faculty must be willing to consider how best to promote learning, trainees must demonstrate an openness to the criticism and discomfort necessary and inevitable in the preparation for a medical career.

Further, when evaluating programs, applicants should take into consideration the learning environment. Observe the interactions between faculty and interns, and question current and former program participants about how and at what frequency feedback is offered. It may also be worthwhile to engage administrators or admissions representatives on how the program structure trains and supports faculty in providing feedback, facilitating difficult conversations, and creating a positive learning environment. While more visible wellbeing investments can be compelling, it is critical to look closely at the structural elements of a program that data shows matter to the lives of residents: hours worked, tasks performed, work-life balance, and the learning environment.

Top Medical Schools Take on Student Debt in Bid to Increase Diversity and Encourage Broader Specialty Selection

Recently, Washington University in St. Louis announced that it was going to commit $100 million over the next ten years for scholarships for medical students and to “enhance and modernize the school’s medical education program.” Up to half of the program’s future students will be able to attend the school tuition-free, with many others receiving partial tuition support. The program will begin with the 2019-20 entering class.

Washington University is the latest in a string of schools working to reduce the student-debt burden associated with medical school. Last August, New York University Medical School shocked and delighted students when it announced that all current and future medical students would be attending tuition-free. Kaiser Permanente, the following February, made a similar offer for its first five graduating classes. Additional schools, including Columbia University’s Vagelos College of Physicians and Surgeons and the David Geffen School of Medicine at UCLA also have created substantial scholarship funds to ease student loan burdens.

The rising cost of medical school debt negatively impacts not only medical students but also the greater public. Students graduating from public medical school programs carry a mean debt of just under $189,000, while those graduating from private medical schools have a mean debt closer to $209,000. This debt load can impact many aspects of public health, including deterring promising students from entering medical school, encouraging those in medical school to opt for higher paying specialties post-graduation, and creating higher stress and lower wellbeing for physicians and those in training. In late April, the AAMC published updated physician shortage numbers, with the projected shortfall of primary care physicians, a lower-paying specialty, ranging between 21,100 and 55,200 by 2032.

The schools offering reduced and tuition-free opportunities for their students believe that reducing student debt will encourage a more diverse applicant pool as well as empower graduates to pursue a broader range of medical specialties. “For most medical students, debt is a significant factor in selecting a school and a career path,” said Eva Aagaard, MD, Senior Associate Dean for Education and the Carol B. and Jerome T. Loeb Professor of Medical Education at Washington University in St. Louis. “We want to help alleviate that financial burden and instead focus on training the best and brightest students to become talented and compassionate physicians and future leaders in academic medicine….This is an investment in our students and in our institution, as well as in the health of St. Louis and the greater global community.”

 While many schools have adjusted their admissions processes to attract more minority applicants, using a combination of pipeline programs, more holistic admissions standards, and a focus on diverse representation on admissions committees, the problem has thus far remained. “From 2014 to 2018, the percentage of black students enrolled in medical school rose from 6 percent to 7.12 percent, according to the AAMC. Additionally, Latino medical students increased from 5.3 percent to 6.4 percent of total enrollment while Native Americans still account for less than one-half of a percent of all medical students.”

While it is still too early to gauge success, NYU has seen promising results in its first application wave since it eliminated tuition. While overall applications to medical schools in the United States have increased by 47 percent, African American, Hispanic and American Indian applicants only increased by two percentage points. At NYU, however, almost 9,000 applications were submitted for the 102 seats in the 2019 incoming class. There was a 103 percent increase from the previous year in applicants who self-identify as disadvantaged, a 140 percent increase in black applicants and a 40 percent increase in Pell Grant recipients. Dr. Rafael Rivera, Associate Dean for Admission and Financial Aid at NYU said, “The accepted pool that we have thus far reflects increased diversity in socioeconomic status, which is an important facet of diversity in the physician workforce that hasn’t gotten the attention it deserves.”

 The other objective of tuition-free and reduced medical school programs is the freedom that it affords graduates to select less lucrative specialties or career paths. The relationship between student debt and specialty preference is well-documented. An article reviewing research on the impact of student debt on primary care physicians, included references to a 2012 study that showed students with larger amounts of student debt are “more likely to switch their preference for a primary care career to a high-income specialty career over the course of medical school” as well as a 2016 qualitative study which found that, “students described their debt as making them feel more cynical, less altruistic, and entitled to a high income.” These findings suggest that reducing the debt, through reduced tuition or increased scholarships, will positively impact graduating students’ ability to select a specialty based on preference rather than need.

 Though only time will fully show the impact of these schools’ commitments to reducing student debt on the physician workforce, there is reason for optimism about the benefits that will be seen for medical students, physicians, as well as the public.

Medical Schools Limited on Use of Race in Admissions Decisions but Still Seek to Promote Diversity

Last week, The Wall Street Journal reported that the U.S. Education Department is requiring the Texas Tech University Health Sciences Center medical school to discontinue its practice of factoring race into its admissions decisions. The medical school agreed to a deal with the Education Department in order to end the long-running federal investigation into its use of affirmative action. In 2003, after the Supreme Court ruled that race was admissible as a factor in admissions decisions in Grutter v. Bollinger, the Texas Tech University Health Sciences Center resumed use of race as a criteria in admissions decisions. In 2004, the Center for Equal Opportunity filed a complaint against the school, and the next year the Education Department began the investigation, which this agreement concludes.

Texas Tech had previously ceased using its affirmative action policy for admissions in the pharmacy school in 2008 and for undergraduate programs in 2013. However, the medical school contended that, “It must continue weighing race in its admissions process because a cohort of doctors from different backgrounds could best serve Texas’ racially and ethnically diverse communities.” However, the recently signed agreement stipulated that the school was not providing an annual review of the necessity of race-based admissions and therefore could not rule out that other factors may provide similar diversity-levels. The agreement also suggested that the medical school use other “race-neutral factors” to meet diversity aims, “such as recruiting students from low-income areas and favoring bilingual or first-generation college students.”

Earlier this week and just following news of this agreement, Kaplan Test Prep released survey results showing that 80 percent of 245 pre-med students surveyed in January 2019 say that “It’s important for the American medical profession to be more demographically representative of the general patient population.” Among the students who agreed with this statement, one commented, “While it is certainly possible to be empathetic and ‘tuned in’ to your patients despite differences in language, culture, etc., it is important for patients to feel like they can relate to and trust their clinician…If American clinicians were more demographically representative of the population as a whole, patients would likely find it easier to connect with a care provider they are most comfortable with.” Those in the 20 percent who did not agree with the statement were more likely to focus on the importance of drive and technical ability in becoming an effective doctor.

Additionally, an earlier Kaplan study with medical school admissions officers showed that many felt competent with their school’s diversity efforts. When the admissions officers were asked to grade his/her medical school on diversity, the majority gave themselves a B (35 percent) or C (34 percent), while fewer rewarded themselves with an A (18 percent) and even fewer a D or F (5 percent).

While it is clear that prospective medical students and doctors see the value in diversity in medical school admissions, the process by which the schools will implement these diversity goals is changing based on the views of the current administration. And these changes should be noted, especially by prospective medical students.

For future applicants: Overall, it is wise to seek experiences that improve your ability to work with others, particularly those unlike yourself. And throughout your application, you will want to speak to these experiences in a manner that showcases your commitment to serving a diverse population of patients, highlights areas where you will bring diversity into the program, and show how you have thrived and what you have learned in diverse environments in the past.

The Opioid Crisis and Medical Education: Adequately Preparing Students is an Ongoing Struggle at Most Medical Schools

There are approximately 91 people per day who die from opioid overdose. And each year, an economic burden of $78.5 billion—a result of healthcare costs, lost productivity, addiction treatment, and criminal justice fees—is associated with the opioid crisis. So why aren’t medical schools adequately preparing students to deal with addiction? A recent New York Times article quotes Dr. Timothy Brennan, the director of an addiction medicine fellowship at Mt. Sinai Health System, who compares combating the opioid crisis with the current provider work force to “trying to fight World War II with only the Coast Guard.” Further, Dr. Kevin Kunz, executive vice president of the Addiction Medicine Foundation, notes that while most medical schools now offer some education about opioids, the content varies widely in terms of depth. Additionally, only about 15 of 180 American medical programs teach addiction as it relates to alcohol, tobacco, and other drugs.

Earlier this week, the AAMC put out a Key Issues statement on the opioid epidemic that linked to a January 2018 survey where AAMC researchers asked Medical School deans about their current or anticipated plans for dealing with the opioid crisis. Almost all, 97 percent of respondents, noted the challenges of teaching and/or assessing students’ knowledge of prescription drug abuse. They referred most frequently to a deficiency in faculty expertise, a lack of time within a crowded curriculum, and difficulty assessing students’ mastery.

Attempting to overcome the named challenges, The University of Massachusetts, Tufts University, Harvard University, and Boston University have committed to using a set of ten competencies to drive their opioid education programs.  At Boston University, addiction education is incorporated into all four years of training and the school has partnered with Dr. Bradley M. Buchheit, an addiction medicine fellow, to train students in assessing and talking with patients about substance abuse.

Other schools are following suit. The University of Central Florida College of Medicine enhanced its curriculum to include both preclinical and clinical education on pain management, addiction risk mitigation, the use of prescription drug monitoring systems, naloxone training, and the CDC’s new voluntary guidelines for opioid prescribing. Martin Klapheke, MD, assistant dean for medical education and professor of psychiatry at UCF noted that “students are taught to fully engage patients and their families in discussing the risks and benefits of different pain therapies.”[i] At NYU, medical students have always received training in chronic pain and addiction, including a week-long pain management curriculum. And now the school is adding additional elements including a pain assessment and management training for all students going into residency programs, as well as a lecture on alternative pain management techniques.

Learn more about the battle against opioids:

[i] https://www.aamc.org/newsroom/newsreleases/464576/medical_schools_confront_opioid_crisis_08042016.html

Your story set apart.