Stopping the Med School 'Arms Race'

Vinay Prasad, MD, MPH


January 31, 2020

Last year, I received an email from a freshman who wanted to work with my policy group—not a freshman in college, but a freshman in high school. I had to wonder: Why would a 9th grader want to spend his free time doing cancer drug policy research?

I suspect that his drive arose from the ever-growing arms race in medical training. Nowadays, it is common for a medical school applicant to have three or more publications. A residency candidate may have a patent. A fellowship applicant might have given not one but two oral presentations at a national meeting.

Academic medical faculty like to joke that if we were applying in today's world, we would not be admitted to medical school. Like all good jokes, it rings true. Students are more accomplished than ever: more research, more volunteering, more clubs, more committees, more travel, more activities, more shadowing. And they achieve this at ever-younger ages. What we did as fellows, they now do as students.

My Path

It makes me think about myself as a high school freshman. Medical school was not on my horizon. Emailing a professor to inquire about research opportunities was beyond my comprehension. I bagged groceries at a Kroger grocery store. I spent most of my time with friends. I read a lot of books. I didn't think about health policy. I thought about girls.

Studying violin at Julliard is more intriguing than playing guitar at a bonfire.

When I was a college student, I didn't start a nonprofit foundation. I wasn't the president of a club. I didn't learn Mandarin while volunteering in Beijing. I was too dumb to patent anything. (And by that, I mean that I was too dumb to know that the patent system is so broken that even a shred of an idea is patentable.)

In medical school, when my classmates signed up for summer research, I traveled to Europe. My first peer-reviewed publication was as an intern. It was only in fellowship that I realized I was interested in academics. If anything, I feel I am ahead of folks in my generation, and yet someone pursuing medicine who was born in the 1990s is probably 10 years "ahead" of me.

Is More Accomplishment Better?

First, it is stressful. I pity the freshman in high school who thinks that working with my team is what he or she should be doing. It saddens me to think that they must be missing some of what it means to be young: friends, relationships, parties, and even disappointment, longing, boredom, and solitude. The chance to be alone for long stretches. The freedom from having to do anything. If you are oversubscribed as a teenager, you cannot truly experience these essential experiences. No one will ever write a bildungsroman about an oversubscribed freshman aspiring to go to medical school—there's no story there.

Motivation must be intrinsic or one is doomed.

Second, our lives become increasingly calculative as we get older. In life, one way to group our actions is by motivation into two broad categories: actions we take out of intrinsic pleasure and actions we take for a secondary purpose (calculative).[1] The medical school "arms race" underway in today's schools means that more of kids' time is spent pursuing things done for a secondary purpose. (And let me assure them: There will be plenty of that as they age.) Youth is an opportunity to experience things simply to experience them. Years later, these are the experiences that forge character and personality.

Third, doctors are socioeconomically disconnected from average Americans,[2] and these activities broaden the gap. I went to high school in the industrial Midwest, and the hardest job I have ever had was in that Kroger grocery store. My back and feet ached at the end of 8 hours. I had to navigate local politics, with its petty rivalries, cruel managers, and kind souls. I was exposed to real work. People from all socioeconomic classes were my colleagues and customers and friends. I still feel that working a physical, minimum-wage retail job in your youth is a vaccination against professional burnout (though, admittedly, not one with 100% efficacy).

What's Behind the Accomplishment 'Arms Race'?

The blame for this arms race rests squarely with our selection committees. Students adapt to the standards we set, and we have become enamored with dazzling CVs that are full of calculative, and sometimes even snobbish, activities. Volunteering in a foreign hospital is more glamorous than bagging groceries. Lab work with an R01-funded principal investigator is more coveted than cooking at a fast-food restaurant. Studying violin at Julliard is more intriguing than playing guitar at a bonfire. The neatly formatted boxes of the American Medical College Application Service form do not ask how many hours you walked around the mall with friends or if you ever had your heart broken.

And we have incentivized these accolades with little understanding of whether they create better physicians in the long term. Most of the studies we have test whether selection metrics correlate with other, short-term measures of student performance during school.[3,4] These results may change when you look further out. For instance, my colleagues and I analyzed whether publications at the time of fellowship application were a predictor of future publications. This metric is commonly prioritized to select fellows with "research potential," yet we found that the metric was little better than a coin flip. I fear that robust prediction modeling (if ever done) would reveal that nearly all of the hallmarks of a "great candidate" in 2020 cannot predict who will (a) do something meaningful in their career, (b) be kind and just, (c) fight for the underdog, (d) demonstrate empathy and listen, (e) work hard and constantly try to improve.

Instead, I speculate that today's metrics more strongly predict candidates who will (a) specialize in orthopedics or other coveted fields, (b) have a laser focus on achieving high Step 1 scores, (c) publish more papers and be involved in more clubs and activities prior to fellowship (still calculative), (d) publish fewer papers after one's final fellowship, and (e) experience professional burnout.

I speculate on "burnout" only because a life spent seeking and receiving external validation beginning at the age of 14 may lead to disappointment as a practicing physician, where accolades and external validation are infrequent and where motivation must be intrinsic or one is doomed.

Changing Our North Star

At this point, the arms race has acquired a life of its own. Inertia is propelling us toward a scenario in which middle school students will be pipetting in Howard Hughes Medical Investigators' laboratories.

As faculty, we must be honest with those who wish to join our ranks. When I wrote back to the freshman who wanted to work in my lab, after inquiring about his life and confirming that he was indeed oversubscribed, I urged him to consider careers outside of medicine. I urged him not to do research and recommended some books I read at his age that shaped my thinking. Like so much honest feedback, I could tell that he was not happy with me.

It could be that high school freshmen seeking to work with health policy professors become the best doctors, but I doubt that. Instead, I hope, for their sake and ours, that it's the kids who waste their time, wander, and make mistakes who grow up to be physicians—the kind we need.

And, of course, only when they are ready.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at Oregon Health & Science University. He studies cancer drugs, health policy, and evidence-based medicine. He is the coauthor of the book Ending Medical Reversal and author of the forthcoming book Malignant: How Bad Policy and Bad Evidence Harm People with Cancer.
Follow him on Twitter: @VPrasadMDMPH

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