Embracing the New Normal and Who Gets to be a Physician
by Adina Kalet, MD, MPH
It is an open secret that it is far harder to get into medical school than to stay in. Only 41% of applicants to medical school are accepted in any given year, while medical school graduation rates are over 95% within six years of acceptance and 96% of graduates go on to match into a residency training program. COVID-19 might change all of that.
Normally, we would be Preparing for Interview Season
For decades, fall meant the arrival of groups of 20-somethings with conservative blue suits and rolling suitcases striding through hospital lobbies and medical school hallways all over the US. These gaggles were invariably trailing either a medical student guide or a bedraggled but authoritative chief resident in a well-worn white coat with clogs peeking out from under scrubpants. It’s interview season, when over 53,000 medical school applicants and 35,000 residency applicants go to great effort and expense, crisscrossing the United States, to chase their dreams.
As they peer into classrooms, learn about schedules, and share lunch with faculty and other applicants, each one hopes to experience that “gut feeling” about the “fit” between themselves and the institution. Meanwhile admissions deans and residency program directors, after sifting through digital mountains of applicant data to select interview candidates, hope to end the day with a sense of who best fits with their schools and programs. While this seems like a sacred rite of passage, it will not be for the foreseeable future.
COVID-19 Impact on Residency Applicants
The Residency Match will change this coming year. On May 11, 2020, the Coalition for Physician Accountability – a cross-organizational group of national medical education organizations – released recommendations to alter “Current Practices of Student Movement Across Institutions for the Class of 2021” as follows:
- Students will not be able to do away elective rotations
- All interviews will be conducted virtually
- The Electronic Residency Application Service® (ERAS®) residency match timeline will be pushed back to allow students to complete their graduation requirements.
The first two, particularly, will fundamentally change the process of residency selection for the coming year. Medical students will be unable to “audition” at their favorite institutions. Residency programs will be unable to glean the intangibles that crop up during day-long, on-site interviews. For the upcoming year, at least, the transition between medical school and residency will change.
COVID-19 Impact on Medical School Applicants
Similarly, aspiring medical students face substantial changes. Interviews and school visits will almost certainly be virtual. MCAT test dates have been canceled from March through May, and more dates will be canceled, if necessary. There is no precedent. We have no idea how this will impact how we decide who gets into the long pipeline toward becoming a practicing physician.
Impact on all Applicants – Some Bad but Some Good
Except for the rare, outstanding, top-tier applicant who needs no interview, most students and residents have educational metrics in the middle of the pack. While they have the most to gain by interviewing well, they will have to be prepared to accept the choice they are offered. This reality will test their humility, tolerance of ambiguity, and integrity. Despite their personal ambitions, this occasion to make the absolute best of their “good enough” option will demonstrate character traits that are critical components of what it means to be a physician.
There will also be some immediate benefits, however. Not having to travel for interviews will save applicants, in aggregate, at least $800,000,000. This represents about $10,000 per applicant, an amount that most do not have and, therefore, would have added to their educational indebtedness. The applicants stay closer to home with the hidden benefits of lower housing and childcare costs. And maybe they only purchase a new sport coat or jacket rather than an entire suit.
Challenges to Medical Schools and Residency Programs
Without campus visits, our medical school and residency programs might find it more challenging to convince the best applicants that Milwaukee is a great place, and that MCW offers a unique sense of “family.” Although virtual interviews, done well, might provide unique affordances, we will likely miss the subtle clues that an otherwise excellent candidate would not be a good cultural fit with the school or program. We will have to create social connections between the current and potential future members of our community while presenting a realistic but optimistic view of what is to come.
While the greatest institutional cost associated with interviewing is for the salaries of people who organize and run the events, there will be savings when institutions and programs do not need to provide food and hotel rooms for interviewees. In addition, interview strategies such as Multiple Mini Interviews, which better predict long term clinical competence than the usual interview approaches, may be more cost-effective and feasible using available technology.
What Opportunities can we Leverage?
All schools and residency programs are committed to increasing diversity in students and trainees. Admissions practices and policies are the most powerful drivers to reduce unconscious bias and ensure that we attract physicians-to-be most likely to practice in underserved rural and urban settings. And while very complex, efforts to rebalance the proportions of specialists and primary care physicians to better meet the needs of the public while managing the quality and costs of care could be partly addressed through admissions policies. We have the potential to learn much in the next year.
Should we Expand Models of Transition between Educational Phases?
There are alternative models where students transition from one phase of education to another. For example, combined medical school-residency programs exist, such as the Education in Pediatrics across the Continuum (EPAC) program at the University of Minnesota and the three-year accelerated track of the NYU Grossman School of Medicine, where schools create efficient training continua focusing on educating the best physicians. We might also experiment with smoothing the UME-GME continuum. What if we accepted a certain number of students into medical school with a guaranteed residency spot at MCW?
Combined premedical-medical school programs have been around for decades. I entered the Sophie Davis School of Biomedical Science at the City College of New York (now the CUNY Medical School) straight out of high school, knowing that – if I worked hard – I would complete both my Bachelor’s and MD degrees with fewer pre-requisites, no MCAT, and a slimmed down medical school application process. I turned out OK? Right? Countries with enviable health care systems have different approaches to applications and admissions, often awarding an MD or equivalent degree after six years of post-secondary education. There are many opportunities for meaningful innovation.
We Must be Kind...
COVID-19 will force medical schools and residency programs to explore new ways to screen, interview, and choose their next cohort of students and trainees. Schools and programs will make adjustments as they navigate these uncharted waters.
For applicants, the loss of the in-person interview means they will have difficulty developing their gut feelings about hidden curricula, faculty engagement, social cohesiveness, educational culture, and commitment to the surrounding populations and places. They will lack the opportunity to suss out the actual differences between the values a program espouses in its written materials and the actual lived experience of the program. Medical school and residency applicants, who often depend on online forums and comments, will find themselves bereft of meaningful advice. They will be forced to find their way through an opaque system for which there is no precedent.
This strange period in history offers us many opportunities to do our work better. I am certain that some of the changes that occur in the coming months will be valuable and enduring while others will not. As we move forward, though, let us remember that many of the applicants will feel adrift and scared. We can remind them that they are where they are because we believed in them and we now reaffirm that we will support them as they move toward becoming caring, character-driving, and compassionate physicians.
Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.
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