“Try a thing you haven’t done three times. Once, to get over the fear of doing it. Twice, to learn how to do it. And a third time to figure out whether you like it or not.”
— Virgil Thomson, American composer
At the beginning of my third year of medical school, before my first rotation, I was “undifferentiated”: I had almost no idea which specialty I wanted to pursue. At the time, I did not consider this a disadvantage, as being undecided in the rotational year is often deemed a virtue by faculty and students alike. Throughout medical school, students are encouraged to keep an open mind, and preceptors tend to think of the undecided student as a tabula rasa; a neophyte they can proselytize. I was raised by two physicians who did not “differentiate” until well into their rotational year, and they did, as their generation tends to say, “just fine.”
Convinced that my lack of professional clarity was an asset, I resolved that my third year would be exploratory, as the rotational year is designed, and not a mere credentialing process — as it is often lived in praxis. But the reality is that what was “just fine” for physicians-in-training even one generation ago is no longer as feasible. Now, the earlier students know their chosen specialty, the more they stand to gain: they conduct research in the field (some even start as early as college) and proceed through their rotations with the daily goal to get dismissed early enough to study for the shelf exam. Without missing a beat, these students apply into their desired specialty, and their foresight confers an undeniable advantage in the form of a longitudinal track record of extracurriculars, research and connections.
This is not intended as a bitter tirade, or an invective against high achievers, or so-called “gunners.” These are people who do what they feel is necessary to secure a future in an increasingly commodified health care system, and there is a degree of “gunner” behavior in all health care professionals. This is also not to say that it is impossible to succeed in medicine without extensive foresight, and many do, whether via shrewdness, innate ability or a gap year to strengthen their resume. What emerges as problematic is that early differentiation is “taught by example and reinforced by a system of rewards” — a phenomenon which opposes the exploratory aims of medical school clerkships.
In its current form, the rotational year offers little room for genuine career exploration. Many students who apply for residencies in competitive specialties consider the year a formality punctuated by shelf exams. Though I doubt anyone would want to attempt such an undertaking, purely for the sake of a thought experiment, I can see the value of doing each rotation thrice, per Thomson’s quote. The first time, to adjust to the daily rhythms and physical requirements of each specialty; the second, to learn and appreciate the science, and a final time to determine whether the specialty is a fit. Of course, students only rotate once in each core specialty, and they are thus expected to accomplish all three objectives on their first try. They must, for instance, study in the evenings to ace the shelf, but sleep enough to be functional during 4:30 a.m. vascular surgery team rounds. Somewhere between rounds, didactics and hours of being surrounded by evaluators, they need to figure out what it is they want to do with their lives.
Many institutions have taken steps to combat the tendency of medical education to function as a credentialing assembly line. The U.S. Medical Licensing Examination (USMLE) Step 1 was changed from a numerical score that determined students’ candidacy for the most competitive residencies to a pass/fail scoring system for examinees from 2022 onwards. Step 2 Clinical Skills (CS), an exam with a 95% pass rate that cost $1,580 to register, was discontinued altogether. In light of the pandemic, multiple medical schools made shelf exams pass/fail and/or adjusted the grade distribution curve for rotations, so the majority of the class received a grade of either honors or high pass.
In the wake of these developments, medical schools, residency programs and students alike are scrambling to ascertain which factors and metrics will be used to distinguish residency applicants. What do we make of a number formerly used to filter applicants that is now, to some extent, nationally discredited? How else will the looming pass/fail transition affect the evaluation of residency applications? A world where numbers matter less and less threatens to prioritize foresight and extracurriculars — aspects of an application which are well known to compound privilege and thereby exacerbate existing educational disparities.
The rotational year has become perfunctory, but it need not be, and there is good precedent for this. Whether or not we studied the humanities in college, most of us pursue liberal arts education — that is, studies founded on the development of general intellectual capacities. This is a strong suit of the American system, in contrast to many of our European counterparts where students are siphoned into either vocational or academic high school programs, and aspiring doctors study medicine for 6 to 7 years straight out of high school.
Can we maintain this spirit of openness and intellectual curiosity, in which an English Literature major is more than welcome in medicine, even as we begin to differentiate? I believe it is possible. However, it will not be easy if early specialization continues to be favored in the evaluation of residency candidates.
Solutions throughout the continuum of medical education should be considered. Medical schools could free up more time for clinical experiences by eschewing sequential basic science courses like Biochemistry and Anatomy in favor of more integrated coursework. In this regard, the University of North Carolina School of Medicine leads the charge. The rotational portion of their curriculum starts earlier and lasts longer, allowing for exploration, specialization and scholarly tracks that apply to all specialties, such as medical education and “Care of the Older Patient.”
As for evaluation of residency applicants, program directors must prioritize equity as Step 1 recedes into the background and leaves a “power vacuum” in its wake. The question of how to evaluate candidates with more research papers is an urgent one. It seems clear that students who commit early are likely to pursue research sooner than their undecided peers. Disparities in publications and other academic work are further exacerbated by extant educational inequities, including students’ writing background and access to mentorship at academic medical centers. Studies have shown that although medical students are aware that research improves their career options, many do not take part in research projects, and the most commonly cited reason is lack of opportunities. While research experience merits consideration in the application process, program directors should maintain a capacious understanding of what goes into a publication and the kinds of students who are more likely to publish.
In the longer term, the pressure to further specialize through the pursuit of fellowship training creates an environment in which early specialization is the norm. For example, though all humans experience pain and will die, fellowship applications for algiatry (pain medicine) and palliative care are solicited from a limited range of specialties. As for the counterargument that the tendency of medicine towards hyper-specialization optimizes clinical efficiency, many would disagree. In a viewpoint published in the New England Journal of Medicine titled Divided We Fall, cardiologist and NEJM correspondent Lisa Rosenbaum argues that the hyper-specialization of modern medicine often causes “breakdown[s] in communication and teamwork” that compromise patient safety. As medicine is progressively balkanized, we must consider the consequences for physician training, patient care and the functioning of the health care system as a whole.
The more medical school and the residency application processes favor early specialization, the less room there is for uncertainty, path changes, mistakes and interdisciplinary thinking. And the more we prioritize professional individuation, the more we eclipse the individual from medicine entirely, as the pressure to differentiate early impairs students’ ability to shape their careers according to their interests and passions. One of every two medical students burns out before residency, and “emotional exhaustion” and “depersonalization” are common causes. Though we may not have the option to try specialties three times, we can work to create an environment in which students can wander, get lost and eventually find their way home.
Image credit: Woldgate Woods, 4, 5 and 6 December 2006 (CC BY-NC 2.0) by lluisribesmateu1969