Every year as March rolls around at medical schools and residency programs across the country, the pressure mounts.
For fourth-year medical students the question is: Will I land a residency slot – preferably one I want – or will I be derailed after all I’ve done?
For M.D. programs, it’s: Will all of our students get slots – the sought-after 100% match that is the stuff of university news headlines, admissions brochures and annual reports?
For residency programs, it’s similar: Will we fill all of our slots, meeting our workforce demands and protecting our national reputation as sought-after programs?
For George Mejicano, M.D., M.S., senior associate dean for education in the OHSU School of Medicine, these answers are emblematic of a system not calibrated to produce the physicians that society most needs – physicians, as Mejicano explains, who are “intent on reducing disparities, improving outcomes in health and making our world more just.”
“Essentially what we have right now is a disjointed system, and there are competing agendas such that what’s best for a given stakeholder group will trump what might be the best for society,” said Mejicano. “Medical students lead with their strengths, burying their weaknesses and applying to a raft of programs – costing time and money – out of fear of not getting a slot. It’s a pressure reinforced at every step of the way by their medical school, the residency programs and other stakeholders that favor confidence over humility and self-reflection.”
House of Medicine looks inward
This is just a flavor of the findings in a blockbuster report issued in late August by the national Undergraduate Medical Education - Graduate Medical Education Review Committee (UGRC), which Mejicano co-chaired.
The committee was chartered by the Coalition for Physician Accountability, which is made up of what collectively is known as The House of Medicine – the very stakeholders called out for reform. They include: all relevant accrediting bodies from the Liaison Committee on Medical Education (LCME) to the Accreditation Committee on Graduate Medical Education (ACGME); the American Medical Association and the American Osteopathic Association; the National Residency Matching Program (which runs “Match Day”); the Federation of State Medical Boards (the regulators); and the National Board of Medical Examiners (the standardized test-writers).
The report, “Recommendations for Comprehensive Improvement of the UME-GME Transition,” includes 34 directives organized around nine themes – from Collaboration and Continuous Improvement and Diversity, Equity and Inclusion to Equitable Mission-Driven Application Review and Optimization of Application, Interview and Selection Processes. The committee’s north stars, said Mejicano: the public good and championing diversity, equity and inclusion.
“This report has the potential to revolutionize medical education in America,” Mejicano said. “The big question is whether or not the recommendations as a set will actually be implemented across the country.”
Breaking the box
The committee’s work grew out of a national conversation that began in 2018 about the use of numeric scores associated with medical licensing examinations in residency applicant screening and selection.
A review resulted in recommendations around the adverse impact of over-emphasizing these scores and embedded racial and demographic bias in the tests. As a result, Step 1 of the United States Medical Licensing Examination (USMLE) series will eliminate numeric score reporting across the country in January 2022.
The Medical College Admission Test (MCAT) is coming under similar scrutiny. National Public Radio’s “the pulse” featured the experience in March of OHSU School of Medicine student Mollie Marr, who had to take the MCAT four times before gaining admittance. She has now earned her Ph.D. in behavioral neuroscience and is completing the M.D. portion of her M.D./Ph.D.
Mejicano co-authored a Letter to the Editor of Academic Medicine noting that the medical schools with the highest average MCAT scores have moderate levels of student body diversity “valuing the cost of maintaining stature in U.S. News and World Report rankings over diversity, equity, and inclusion.”
He and OHSU School of Medicine colleagues Tracy Bumsted, M.D., M.P.H., associate dean for undergraduate medical education, and Rob Cloutier, M.D., MCR, assistant dean for UME admissions, call for making the MCAT pass/fail to “leave open the door to more multidimensional discussions of what our applicants offer the profession and future patients without sacrificing quality.”
Med school to residency transition becomes target
Such discussions led to the larger focus around reforming the inherent and pervasive challenges associated with the medical-school-to-residency transition and to the formation of the UGRC committee. The group’s 30 members included everyone from public members to medical students to clerkship directors to professional society leaders and members of organized medicine stakeholder groups.
Additional recommendations are in such areas as:
- Requiring anti-racism and diversity, equity and inclusion training for all members of the medical education community to avoid perpetuating mistreatment
- Making the residency interview process more equitable
- Better preparation of medical students for residency
- Ending the residency applications “arms race”
As the AAMC’s article about the report notes:
“Worried that they won’t win a slot, residency candidates have been filing more and more applications. Between 2016 and 2020, the average number of applications that candidates submitted rose more than 8% from 87.7 to 95. International medical school graduates, who often face additional hurdles in the quest for a residency slot, have hit an average of 136 submissions.
“This year, we received 5,800 applications for 24 positions. It’s just not possible to thoroughly review most of them,” explained Richard Alweis, M.D., a UGRC committee member and associate chief medical officer for medical education at Rochester Regional Health in New York.
Candidates might apply to fewer programs if they better understood where they had a shot at acceptance and if programs looking to winnow their applicant pools had better information, the UGRC suggests.”
A path to transformation?
Taken together, said Elise Lovell, M.D., UGRC co-chair and emergency medicine residency program director at Advocate Christ Medical Center in Oak Lawn, Illinois, the recommendations are “transformational.”
Committee member Grant Lin, M.D., Ph.D., a pediatric resident at Stanford Health Care in California and a committee member, agreed.
“For the past 10 years or more, we've been stuck in the same place,” he said. “The recommendations are a monumental step in breaking through that.”
The UGRC has handed off its recommendations to the Coalition for Physician Accountability for their consideration and implementation. As Mejicano notes, there are a few of the recommendations that are within the scope of individual schools to implement – such as OHSU’s work to analyze clerkship grading for bias and the decision to stick with virtual residency program interviews for the upcoming admissions cycle because it levels the playing field in terms of time and cost to fly to multiple sites.
But he said that to fully implement the recommendations across the board will take many organizations working together and agreeing to the reforms. And that may require restructuring some of the organizations’ financial incentives, since they may have products and services which depend on the status quo.
But Mejicano witnessed the will during the impactful work of the committee and hopes there will be a way.
“To get a group of people to put their personal agendas aside and come to a common understanding of what the country needs, what society needs and what we need to do to get there was incredibly gratifying for all of us,” Mejicano said. “To have the House of Medicine – all of organized medicine – say, ‘We have to fix this.’ Is a once-in-a-generation opportunity.”