Residency Competition Continues to Increase
Everyone goes into medical school expecting it to be difficult, and rightly so. American medical schools are some of the most exacting scholastic institutions in the world, placing huge demands on students who are often fresh out of college. One byproduct of the increasingly selective nature of medical schools has been the fostering of a brutal competitive spirit inside each school – with students going out of their way to ensure that they rank higher than their peers for the purposes of residency selection and class ranking. Many experts believe that a healthy degree of competition is necessary to create a truly rigorous academic atmosphere, but some believe that a high level of competition is actually detracting from the medical school experience and is creating single-minded students that have a very one-sided approach to medicine. Citation? Who are these, "Many experts." What is the "very one-sided approach to medicine"?
Decreasing Number of Residencies
Competition to get into medical school is already fierce –with only around 20% of applicants across the country getting into one of the schools they applied to (Fayerman, 2012). Even if they make it into a medical school, these top-tier students will find themselves going through yet another selection process as they attempt to qualify for one of the limited residency slots. The number of funded residencies has remained steady since 1997, even though the number of medical school students has nearly doubled in that time frame (Smith-Barrow, 2013). This has created a bottleneck where many U.S. medical grads are unable to secure a residency despite having massive student loans and being otherwise great students. Why should going into debt make it easier to get a residency?
According to an article in the New England Journal of Medicine, attempts by Congress to increase the number of federally funded residencies are too slow to prepare for the increased number of patients that are expected following the passage of the Affordable Care Act. Citation? A journal article is an individual's perspective on something or a presentation of data. Just because the NEJM publishes that funding is "too slow" doesn't make it true. Citation is required at a minimum or quotation of the data directly.
As with all supply/demand imbalances, the market struggles to correct the imbalance – but lags behind the imbalance when structural problems (the low number of medical schools and lack of instructors) make the market less flexible. Incentives for bright students to enter medical school are high as ever, with salaries ranging into the seven digits for surgeons that complete the most prestigious residencies Citation please showing that any resident makes 7 figures coming out of residency or that the more "prestigious" the residency the higher the salary. , and the difference in pay rate between medical professionals in different fields has never been higher. For example, a family medicine practitioner with a sub-par residency might expect to make $200,000 per annum – not a great terminal rate of pay considering the $300,000 debt load they can be expected to carry. What exactly is a "sub-par" residency? Are all FM residencies "sub-par" are they all non-"prestigious"? From the Physician compensation report 2014, the average FM practitioner (NOT those just starting out) will make 176k this year.
Increased Competition between Students
Since medical students are taken from the top tier of college graduates, competition comes down to tiny differences in grades and evaluations Citation? After being on an adcom and having family sit as faculty adcoms for decades, this certainly is not true. – leading to a level of paranoia among many medical school students that any attempt to help others with studying or preparation might lead to a reduction in their own relative class rank. Citation? In particular, D.O.s appear to be negatively affected by the increase in competition for residency spots. M.D.s are more likely to have higher scores on the boards and on their overall grades – so D.O.s are finding it difficult to get into competitive residency slots, and they are under-represented in plastics, radiology, dermatology, etc. Why should DOs be equally represented in those fields? (Adams, 2014). <-- This citation has nothing to do with DOs or their difficulty getting into competitive residency positions.
According to one article , Match Day is even more stressful than the medical school admissions process itself, because the consequences can be so serious for doctors who fail to find a match. Citation? What article? This makes no sense. If you don't match, you find out well in advance of match day so that you can participate in the SOAP. IF medical school graduates are unable to match on their first try, they can spend an entire year out of the field while they reapply – the whole time being on the hook for medical school loans that are impossible to pay back without a job in the field for which they trained. It is not impossible. It is difficult. Residents don't pay back their loans (if they have large loans) in the first year. Many if not most do income based repayment based options for many years which would be no different for people that don't match.
For individual medical school students – increased competition for residencies can be the ‘breaking point’ that forces students over the edge into cheating and sabotage. While medical school is generally a cooperative environment, where students are willing to help each other study for tests and perform assignments, the prevalence of cheating might be increasing thanks to competition between students. According to a study in the Southern Medical Journal, academic burnout due to competition is a correlate for cheating during medical school – and many medical schools reported cheating rates of up to 58% on certain assignments (Kusnoor, 2013). Your grades on things that you can cheat on have little to do with what residency your end up at.
In an earlier study in the Journal of Academic Medicine, nearly 39% of all medical students reported that they had witnessed cheating during their time at medical school. While some of these students might have a predilection to cheating due to their cheating during an undergraduate program (and thus being incapable of the work at a medical school) the data “strongly supported the role of environmental factors” such as the level of competition between students for limited residency slots (Baldwin, 1996). Your grades on things that you can cheat on have little to do with what residency your end up at.
In a survey that was passed out to 461 students at Dundee Medical School, the majority of students correctly identified that a variety of cheating scenarios were ethically wrong, but there was some confusion on whether or not some of them constituted actual cheating (Rennie, 2001). It has long been a practice for medical school instructors to hand out copies of questions prior to an exam – since the questions are generally used to solicit information proving deeper understanding rather than simple memorization – but many board evaluators consider this to be academic misconduct in and of itself (Ruhnke, 2013). Your grades on things that you can cheat on have little to do with what residency your end up at.
American medical schools do appear to have a lower instance of cheating, based on self-reported data from anonymous questionnaires. However, this points to the same essential problem – where medical school cheating rates are directly influenced by the relative reward of getting into a competitive residency. In Croatia, medical students that fail to get into a residency after their fifth year of medical school are essentially dropped from the program, wasting five years and thousands of dollars in lost wages and tuition payments. It correlates that Croatian medical students would cheat more – and they cheat at a staggering rate of 78% based on a large cross-sectional study (Kukolia, 2012). You can't jump into an ENTIRELY different medical system and then start pulling analogies. There is next to zero reward for cheating in the pre-clinical years of medical school (where cheating is documented as relatively rampant certainly compared to on Step 1 or in the clinical years).
What can be done?
According to the British Medical Journal, cheating in medical school is punished at a rate that is lower than cheating in undergraduate colleges, because medical schools implicitly trust the integrity of their students due to high admissions standards (Smith, 2000). However, when everyone in a school has the same high admissions standards, but are forced to jump through increasingly small hoops to graduate and practices, the incentives for cheating in medical school are much higher. Why are the incentives higher if getting better grades in your pre-clinical classes has very little impact on residency applications.
To begin with, a reduction of cheating in medical schools would naturally follow a reduction in the overall competiveness of residencies. The current residency system is broken because it encourages a massively tiered system of success for students that are already among the best in the country. While the differences between the top 10% and the bottom 10% of medical school students are relatively low Citation for this? by the time poor-performing students are weeded out early in school, the difference in the top residencies and the bottom residencies are massive in terms of expected post-residency salary. How do you define, "top residency" or "bottom residency"? Citation for expected differences in post-residency salary? A graduate of a top-level residency might make up to five times as much per year as someone that went to a lower tier residency, and this isn’t even considering the people that fail to get a residency and cannot practice medicine immediately. Citation?
For individual medical schools, reducing cheating is a matter of making punishments clear, fair, and transparent – and profiling the types of students most likely to cheat. In the Journal of Experimental Society, three psychiatrists found that students were most likely to cheat when one of the following was true (Williams, 2010):
1. Students are unprepared, either because they are fundamentally unequipped to handle the course load (unlikely in medical school) or the demands placed on them by multiple classes are too high.
2. Students do not believe the assignments are relevant. When students don’t see a connection between assignments and their overall education – they respond by minimizing the time they must spend on those assignments, sometimes through cheating.
3. Students with a high degree of self-confidence, cynicism, and a lack of emotional expression. According to the study, students that feel entitled to good grades might be less likely to see a problem with cheating, and this type of student is the stereotypical ‘profile’ of a high-achieving medical school enrollee. "self-confidence, cynicism, and a lack of emotional expression" Citation that medical students are statistically more likely to be any of these 3.
Conclusion
Residencies are getting more competitive Accurate, medical students are under increasing amounts of pressure, and some students respond by cheating. Why should the majority of medical school students care about something that is going on in an admittedly small portion of the community?
Medical schools are under intense scrutiny throughout the country, and rightfully so. The average citizen places a degree of trust in their doctor that is unmatched in other professions, and much of that stems from their belief that medical schools are unimpeachable. Never mind that this is not true, this is not supported by anything in the article, why is this a part of the conclusion? Any crack in the façade of medical school honesty and standards would jeopardize the entire profession – making it harder to justify the position that doctors hold in the greater community.
Medical school cheating affects everyone that competed for a residency, even if they are not personally cheating themselves. With such slim margins separating students from each other, a student that cheats to get a slightly higher grade on a particular assignment or lab might find themselves several positions ahead in the class rank as a result. This punishes the non-cheating students, forcing them to compete on a playing field that is no longer level. Cheating betrays the egalitarian nature of medical schools, and it reduces the incentive for honest students to stay honest. None of this is actually supported by this article.
