In July 2022, the Doctor of Medicine Program at Northeast Ohio Medical University welcomed 172 new first-year medical students. Of those 172 matriculating students, 115 did not receive their bachelors’ degrees in 2022. 67% of our incoming class joined us after one or more gap years.
But wait. There’s more.
Many people may not be all that familiar with NEOMED to be honest. This lack of name recognition occurs despite 2023 arriving as our 50th year in higher education since our founding in 1973. Many people may remember us as “NEOUCOM” when we delivered the M.D. for a dual-degree, six-year, combined B.S./M.D. program. As with many popular staples of 1973 culture that have now passed into history for more contemporary preferences – AMC Pacers, leisure suits, glam rock, and styrofoam Big Mac containers — we “sunsetted” that accelerated, dual-degree arrangement after we became a state university of Ohio many years ago.
Today, you would find NEOMED nestled between Florida State University and Tulane University if you sort allopathic medical schools by median MCAT score in the 2022 AAMC Medical School Admissions Requirements (MSAR) report.
However, we extend early assurance opportunities to undergraduate students enrolled at many public and private colleges in northeast Ohio. Students from our early assurance network comprise about 30% of our matriculating class. If you set aside this early assurance candidate pool arriving at NEOMED directly from college graduation, 83% of our incoming entering M.D. class completed one or more gap years before entering NEOMED.
I don’t think we are unique in this regard whatsoever.
Origins of the Medical School Gap Year
Pre-health advisors know how students spend their gap years because these are your students. The life experience gained in clinical employment as scribes, health coaches, CNA caregivers, and other fields is invaluable for many directly applicable reasons and in general terms of maturation. With meaningful shadowing opportunities decreasing, clinical employment has moved from nice-to-have to an expectation.
Many candidates also spend gap years completing advanced degrees preparing them for medical school curriculum or completing clinical or translational research hours that undergraduate students simply can’t manage when competing with class obligations. And of course, gap time provides the opportunity for hundreds of focused hours of preparation for the Medical College Admission Test (MCAT).
We can debate the relative value of the MCAT in shaping great doctors. We must acknowledge the irrefutable disparate outcomes by demographics. We can go back and forth discussing what the predictive correlation really means when forecasting student success in medical school. But what is beyond discussion is the reality that an allopathic medical school education will consist of many more high-stakes standardized tests from the National Board of Medical Examinations (NBME) including the United State Medical Licensing Exam (USMLE) series that candidates must learn to complete with proficiency to practice medicine.
Physicians in practice maintain board certifications inclusive of examination requirements. Not all physicians must be exceptional test-takers, but all physicians are proficient test-takers. These skills are honed by the MCAT process. It just comes with the territory. To our knowledge, the USMLE has never changed the results of one step exam upon receiving a letter stating, “I just feel that my exam score does not reflect the effort I put into preparation.”
That’s just not how any of this works.
There are two additional components that undergraduate pre-health advisors may not be privy to: the hyper-competitive M.D. candidate pool and residency match.
If results from the dedicated time to boost MCAT scores and to raise BCPM grade profiles from graduate coursework are not enough to differential candidates, then holistic review most often draws a hard line between gap year and direct from undergraduate candidates.
A review of our matriculating candidate pool at NEOMED shows that regular decision candidates present about three times the number of research hours compared to our early assurance direct from undergraduate students. They also bring about twice as many clinical and non-clinical volunteer hours, poster presentation hours, and leadership experience hours along with much higher MCAT scores. This isn’t anyone’s fault or a commentary on the shortcomings of individual candidates. Quite the opposite on a 180 degree scale!
All things being equal, our undergraduates simply do not have enough time to put together the resumes that gap year students have. File readers see this manifestation in nearly every holistic review. Interviewers see the difference life experience makes. The salient takeaway is that the times have changed. What was effective in the 20th century is simply no longer competitive in 2022.
Nearing medical school graduation, our students face an increasingly challenging post-graduation residency match process. The growth in allopathic and osteopathic medical school enrollment, coupled with the combined M.D. and D.O. match process now means that there is an emerging residency scarcity. As clinical entities seek maximum efficiency to deliver health care faster, better, and cheaper, they fastidiously study what drives revenue and what drags revenue. Treating more patients drives revenue. Treating fewer patients drags revenue. The valuable time teaching residents to become the next generation of practicing physicians is time not spent maximizing the treatment patients. Medical school enrollments grow. Residency slots do not grow as quickly, if at all.
Medical Education as a "Pass-Fail" Culture
The transformation of medical education to a “pass-fail” culture coincides with increasing competition for residencies. Unlike undergraduate curriculum, pre-clerkship medical school curriculum is graded on a pass-fail basis nearly universally. Post-clerkship curriculum is moving toward increasing pass-fail and narrative grading. And for the first time in 2022, the USMLE Step One examination was graded as pass fail. The ability for medical school students to differentiate themselves to clinical residency selection committees is now limited to mostly out-of-classroom cocurricular experiences until almost the end of the fourth year.
Medical school students feel the same squeeze to resume-build as undergraduate students without gap years. They must rely on the experiences built during gap years before medical school matriculation to present competitive residency applications. Residency candidates without these gap year experiences are hard pressed to catch up without the disruption of a leave of absence in medical school.
The University of Texas Southwestern Medical Center conducts an innovative longitudinal study of the residency match process. You can learn more about the Seeking Transparency in Application to Residency, aka Texas STAR reporting system here. The number of membership in honorary societies, research publications, volunteer experiences, and other out of classroom experiences that the typical matched candidate presents is daunting to view. The typical residency match medical student now applies to 41 residency programs to gain access to just 15 residency interviews per this report. The importance of a residency-ready career vita cannot be overstated.
The Strong Case for a Gap Year
The case for the gap year for medical school candidates seems pretty compelling, doesn’t it? Then you meet the undergraduate families. What is a pre-health advisor to do when caught between the rock of Dave Ramsey’s financial planning advice accepted as gospel and the hard place of medical school admission? Undergraduate admission counselors and pre-health advisors rarely work with families possessing the knowledge to fully appreciate the value of horizon planning for residency match. They work with parents who have carefully planned advanced placement and college credit plus curriculum for talented students who have sacrificed and saved for a decade or more. Their focus in on how fast students can complete undergraduate work to start medical school at age 20 straight from college.
How do you explain to these earnest families that callow students joining a peer group of adults in their mid-20’s with advanced degrees who have been employed as scribes rounding with physicians or paid to publishing research studies is most likely a colossally bad idea? How can you help curate them toward a fuller understanding that a 38 year career in medicine practicing in a field arrived at with intentionality is an infinitely better life choice that a 40 year career practicing in a field without affinity? Or worse yet, failing out of medical school?
This is often an uncomfortable conversation. What can a friendly pre-health advisor do?
- I used to work for a gentleman who would say, “in God we trust. All others bring data.” Reach out to people in medical school. I know that I am happy to exchange emails or speak with undergraduate advisors. We often have access to data and trend information from sources that are not readily available. I know that I benefit tremendously by learning about trends in undergraduate education and post-secondary preparation from these conversations as well.
For example, I would think sharing the fact that an allopathic medical school in the region enrolling over 80% of entering students with gap year experiences might have an impact. Discovering how income-based loan repayment schedules, public service loan forgiveness programs, and National Health Service Corps programs for physicians mitigate and forgive debt may prove helpful. Feel free to use us collegially as another voice. - Build up a comprehensive pre-health portfolio in addition to a pre-medical education program. Reduce or eliminate any co-curricular and faculty advising silos on your campus. Pre-dentistry should intermingle with pre-medicine and pre-pharmacy and any other professional clinical provider co-curricular clubs and advising tracks. You can give your students and families the ability to grow and learn as much as possible about the realities of their 21st century clinical educational choices. The long-tunnel syndrome might present enough of a barrier for some students to make choices other than allopathic medical school.
This is not a negative. Pharmacy providers most often start Pharm.D programs without baccalaureate degrees and begin provider careers in a total of 6 or 7 years after high school graduation. Physician extenders such as physician assistants and anesthesia assistants complete graduate degrees in two to three years and are in high demand. The more experience your students gain, the better equipped they are to discover the right match for their health career goals. - Consult with your peers as much as you are able. The challenge in higher education right now is that resources are declining reflecting enrollment trends driven by demographic and college participation rate changes. Just when you might need to do more as a pre-health advisor you are asked to do more with less. And the reality is that means you may have to re-prioritize and give up things to start new initiatives.
Colleagues as sounding boards are invaluable. Be sure to actively participate in state level professional associations that often are not as cost prohibitive as national organizations as you see budgets disappear. Leave the competition to the admission and enrollment folks.
The iconic boomer Bob Dylan famously crooned “the times they are a-changin’” to usher in an era of rapid disruption. The themes of that generational anthem certainly apply to allopathic medical school preparation and post-graduate residency match today. While successfully curating our students and their families to focus on “the long game” may not be easily accomplished as they, too, face additional challenges and uncertainties, the importance of serving our clients in stewardship of their aspirations always remains our most important guiding principle.
Until next time…
Have a thought or something to add? Or just want to give me another perspective? I might use it in the next blog. Feel free to continue the conversation at JBarrett1@neomed.edu.
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Whenever I speak with college advisors, faculty who mentor students, or career counselors, their curiosity and the depth of their questions always impress me. So does their motivation to help students. One week I thought it might be helpful to share thoughts and answers to frequently asked questions to a group in our region, so I dedicated several hours looking up names and emails college by college in our region. If you would rather not receive these about once-a-month, please feel free to opt out by unsubscribing via email. My intention is not to annoy anyone!
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