Category: Medical Education

Continuing medical education (CME) is required for all physicians in order to maintain medical licensure. For example, here in Ohio, we must have 50 hours of CME credit every two years to keep our medical licenses. There are a lot of ways to get CME but the costs can vary substantially.

• Hospital grand rounds. Many hospitals provide free grand rounds lectures for physicians on their medical staff with one grand rounds equalling one CME credit hour. But it is difficult for most physicians to block out an hour each week to attend an in-person lecture – maybe they work night shifts, maybe the grand rounds conflicts with their operating room block, or maybe they have an outpatient clinic a distance from the hospital. For any number of reasons, most physicians are unable to attend the hospital’s 8-9 AM Thursday grand rounds. It still costs the hospital money to produce the grand rounds with administrative time to maintain CME accreditation and honoraria expenses for speakers. But the hospital generally provides CME for free as a perk to physicians. Nevertheless, every dollar that the hospital spends to put on a grand rounds is a dollar that they cannot pay the physicians in salary.
• Medical conferences. Every national medical society has an annual meeting. As a pulmonary/critical care physician, I often attended the annual CHEST (American College of Chest Physicians) and ATS (American Thoracic Society) meetings. These are usually held in convention centers at large cities once a year and last an average of about 4 days. You can get a lot of CME credit by attending lectures and symposia with the potential of getting 25 CME credit hours by attending one medical conference. But it comes with the cost of airfare, hotel stay, conference registration, food, and taxi/Uber fare. Using the 2026 CHEST conference in Phoenix as an example, airfare is about $550, hotel stay is about $1,000, conference registration is about $1,300, taxi/Uber is about $50, and food is about $300. The total cost for the conference is approximately $3,200.
• Professional societies. Many physician professional organizations will provide free online CME to members. But you have to pay an annual membership fee to access that CME. As an example, the American Medical Association has 64 online CME credit hours for members but the annual membership fee is $420/year.
• Professional society-sponsored. Other professional societies will sponsor online CME that can be purchased, with society members often getting a discount on the purchase price. As an example, the American College of Physicians offers up to 165 hours of online lecture recordings from its annual meeting for $1,500. East hour of recorded lecture provides one CME credit hour. This is a less-expensive alternative to attending the annual meeting in person.
• Medical journals. Many medical journals will provide free online CME to subscribers. As an example, the New England Journal of Medicine has 300 online CME credit hours available to subscribers. An annual subscription is $190.
• UpToDate. Since its inception in 1992, UpToDate has emerged as the main online reference for many physicians. It offers CME credit for reading “chapters” about thousands of medical conditions and medications. The subscription cost is $500 per year.
• Webcasts. Many academic medical centers provide online webcasts or podcasts for a fee. As an example, the OSU MedNet-21 webcast provides 40 hours of CME webcasts and podcasts each year at a cost of $25 per credit hour. As a disclaimer, I was the host/moderator of OSU MedNet-21 for 23 years.

Taking these as examples, it is clear that there is a huge difference in the cost of the various ways to get CME credits. Taking Ohio’s medical licensure requirements as typical for state medical boards, a physician must get at least 25 CME credit hours per year to maintain licensure. To get those 25 CME credits, the graph below shows the cost per credit hour between the various options.

At $128 per credit hour, attending a national medical conference is the most expensive way to get CME and if the sole reason for attending is for CME purposes, it is a poor investment. However, there are many other reasons to attend national medical meetings – networking with peers, access to the latest research study results, ability to present one’s own research, and time away from clinical practice to focus purely on learning. Moreover, these meetings are usually in desirable travel destinations, allowing physicians to make mini vacations out of attending a conference. Many employers will reimburse the cost of attending one conference every year as an employment perk so the conference may not cost the physician anything directly out of pocket. However, if the employer is paying for the cost to attend a conference, that is money that is not being paid directly to the physician in salary.

Getting online CME from a professional society that the physician is a dues-paying member of is relatively inexpensive. Being a member of the American Medical Association gets you access to CME at $17 per credit hour for 25 CME credits. Most physicians belong to at least one professional society so this can be a very cost-effective way to keep up CME credits.

However, online CME courses that are sponsored by professional societies but not offered for free can be quite expensive. To get 25 credit hours of online CME through the American College of Physicians every year would cost $60 per credit hour.

Subscribing to medical journals is one of the least expensive ways to get CME. At $8 per credit hour, a subscription to the New England Journal of Medicine is a bargain.

An annual subscription to the online reference UpToDate will get you CME at $20 per credit hour. This is a particularly efficient way to get CME since most physicians who use UpToDate use it primarily to look up the current recommended approach to diagnosing and treating various conditions that their patients have. So, many physicians subscribe to UpToDate for its use as a reference and then get the CME credit as a bonus for reading that material.

Webcasts, such as OSU MedNet-21, cost about $25 per CME credit hour in order to get the 25 credit hours per year required for medical licensure. This can be a great option for physicians who like to get their continuing medical education in a lecture format, like a grand rounds, but with the advantage of watching on-demand at a time that is most convenient for the physician.

The bottom line…

The least expensive way for most physicians to meet their state’s CME requirements is to find a hospital that provides free CME to grand round attendees. But because attending a grand rounds each week at a set time on a set day is not possible for most physicians due to conflicts with patient care, the most practical way to get inexpensive CME is by subscribing to a medical journal that offers free CME to subscribers or by becoming a member of a professional society that provides free CME to members. UpToDate is slightly more expensive but allows physicians to get CME for topics that they were going to look up and read about anyway. Webcasts are a cost-effective way to get grand rounds-type CME on-demand. Professional society sponsored online CME courses and attendance at a professional society annual meeting are the most expensive ways to get CME, although there can be other reasons why a physician might want to attend a conference other than purely for CME purposes.

January 20, 2026

Currently, 70% of graduating medical students owe money on educational loans. The average amount of these loans is $228,000 ($215,000 from medical school and $13,000 from undergraduate college). A new Federal law limits the amount of Federal loans to $50,000 per year of professional school and $200,000 total for all of undergraduate and professional school combined. The result is that most medical students are no longer able to afford medical school on just Federal student loans in combination with their personal savings. Their only options are to either take out private commercial loans or obtain scholarships.

Medical school is expensive. The average cost of tuition, fees, and insurance for an in-state resident at a public medical school is $48,000 per year. Private medical colleges are more expensive and cost an average of $68,000 per year. However, there is considerable variation between medical schools and between different years of medical school. For example, at the Ohio State University, the cost of tuition and fees for years 1 & 2 is $32,000 per year and for years 3 & 4 is $48,000 per year for Ohio residents. For non-residents, the cost at OSU for years 1 & 2 is $57,000 per year and for years 3 & 4 is $58,000 per year. Add to that the cost of books, supplies, transportation, living and personal expenses at an average of an additional $30,000 per year. This means that the average total cost to attend a 4-year public medical school as an in-state resident is $312,000. For a private medical college or an out-of-state resident at a public medical college, the average total cost is $392,000!

The result is that no medical student can pay for medical education with Federal student loans alone. Options for students are to ask their parents for financial support, to work for a few years between college and medical school, to get scholarships, or to take out private commercial loans. Nationwide, 65% of medical students have non-loan financial support, usually scholarships or grants. Increasingly, medical students take a “gap year” between college and medical school. As discussed in a previous post, 73% of medical students reported taking at least 1 year between college graduation and medical school; 48% reported taking between 1 and 2 years; 16.5% reported taking 3 to 4 years, and 8.7% took 5 or more years off. Although there are numerous reasons why medical students take gap years, 40% reported that the main reason was to earn money to pay for medical school.

Commercial student loans are often the only other option for medical students. After all, banks consider medical students good loan risks given that when they become attending physicians, they will not have difficulty getting a job and they will have a relatively high salary. However, commercial student loans come with a very high cost with annual interest rates as high as 18% (Federal graduate student loans are currently at an annual interest rate of 7.94%). These commercial loans often come with variable interest rates that start off very low but then rapidly balloon upward into double digits. The bottom line is that commercial loans in the long run come with a higher interest rate than Federal student loans. Furthermore, unlike Federal student loans, commercial loans generally do not have income-based repayment plans that can lower payments during the years of residency and fellowship. Also unlike Federal student loans, commercial loans are not eligible for PSLF (public service loan forgiveness). Because of these factors, commercial loans are the last resort for most medical students trying to finance their medical education.

How scholarships can help

With the new Federal loan limit of $200,000 per medical student, financial need-based scholarships are more important than ever before in order to cover the gap between the cost of medical education and the Federal student loan limit. To have the greatest impact, these scholarships should be need-based rather than merit-based. Let’s face it, you’ve already got to be really, really smart to get into medical school. As a result, merit-based scholarships award money to only the smartest of a bunch of very smart students. On the other hand, need-based scholarships ensure that those students who are smart enough to get into medical school have the financial ability to attend. Otherwise, these students may find the cost of medical school to be an insurmountable barrier and choose to go into a different career.

Most scholarships come from endowments into scholarship funds. These funds are designed to generate money to award scholarships indefinitely. They are therefore invested into institution investment portfolios in order to generate predictable annual returns. Thus, most scholarship funds will award 4% – 5% of the fund value each year in order to continue awards in perpetuity. Given that the new Federal student loan limit for medical students is $200,000 and that the average student loan debt for graduating students is $228,000, there is currently an average $28,000 gap ($7,000 per year for 4 years) that each student needs come up with to attend medical school. A scholarship fund that awards $7,000 per year would need to maintain a balance of between $140,000 and $175,000.

But… the problem with the gap year

Many students take gap years to earn enough to cover the difference in the cost of medical school compared to what they can borrow in Federal loans. When a student takes a gap year between college and medical school, that student enters the physician workforce a year later than if the student had gone straight into medical school after college graduation. Most medical students now take at least one gap year and 1 out of every 12 students take five or more gap years. Medical school admission committees like students who take gap years because of the perception that these students are more mature and are more certain of their career choice.

But gap years are terrible for society. Doctors who took gap years do not retire at an older age than those who did not take a gap year. Therefore, taking a gap year results in a shorter career as a practicing physician. Shorter careers result in a smaller physician workforce and a greater shortage of physicians. For taxpayers who subsidize public medical schools, it means that those taxpayers are getting a smaller return on their investment into every medical student who takes a gap year. Gap years are also terrible for physician financial health. If taking a 3-year gap between college and medical school results in a physician working 3 fewer years over the course of their career, then that means the physician has 3 fewer years to save for retirement while paying off student loans. Taking a 3-year gap results in a 10% shorter career as a practicing physician. A medical education can be a great financial investment but only if you then work enough years in clinical practice to derive the benefit of a physician income.

I would argue that the target for an annual scholarship award should be higher than $7,000 so that students do not need to take gap years in order to pay for the cost of medical education that is not covered by Federal loans. From a societal standpoint and from a physician financial health standpoint, we should be doing everything possible to eliminate gap years, rather than encouraging them. Having an average annual scholarship award of $10,000 – $12,000 would pay for the average cost of medical education not covered by Federal student loans and also eliminate the need for most students to take gap years.

So, how large should scholarship funds be?

The reality is that average financial needs are just that… average. Some graduating medical students have education debt that far exceeds the $200,000 Federal student loan limit. Maybe a student had to borrow the entire amount for both undergraduate college and medical school. Maybe a student could only get into an out-of-state public medical college with high non-resident tuition. Or maybe the student could only get into a costly private medical college. Maybe the student really wants to go into family medicine, a relatively low-paying specialty, but feels pressure to go into a surgical specialty that pays several times more than family medicine in order to be able to pay off student loans. For any of these reasons, some students may need larger annual scholarship awards than others. A $10,000 annual scholarship award might completely fill the needs of one student but another might need a $100,000 annual scholarship award to have the same impact.

But for simplicity, let’s say that a scholarship fund’s annual award target is $10,000. To generate that annual award, the fund balance would need to be between $200,000 – $250,000. Most of us do not have a quarter of a million dollars to donate as a charitable contribution to create a scholarship. But there are other options.

• Contribute to existing scholarship funds. Every medical school will have multiple scholarship funds that anyone can contribute to. Many medical schools have class funds where physicians who graduated in a given year can donate to their class scholarship fund. When selecting a scholarship fund to donate to, look at the requirements for different scholarships – some will be merit-based, some will be financial need-based, and others might be for students coming from a particular hometown or high school.
• Utilize a donor-directed fund. In a donor-directed fund, you donate to the fund and take a charitable deduction from your Federal income tax return that year. The fund then grows tax-free until you direct the fund administrator to disperse some or all of the funds. The disbursements can be made as scholarship awards and you can dictate the application requirements, such as financial need or desire to practice in a underserved area.
• Put it in your will. Every college of medicine has development officers who can advise you on putting a contribution to a scholarship fund in your will. If you have a trust, you may need to have your own attorney modify the trust documents to include a scholarship contribution. The advantage of this approach is that if you live a long time and need all of your money, you can spend it. But if you die earlier than you expected, the money left in your estate can be put to good use as a contribution to a scholarship fund.
• Charitable gift annuity. With a charitable gift annuity, you make a cash or stock contribution to a charity, such as a college of medicine scholarship. The charity then pays you a guaranteed fixed percentage of that contribution every year for the rest of your life. At death, the remaining amount in the annuity goes to the charity., A typical annual percentage would be about 5% – 6% for a donor in their late 60’s increasing to about 9% for a donor over age 85. This allows the donor to have a predictable income stream if the donor lives longer than they expect while still ensuring that there is a substantial contribution to the charity.

Now is a particularly good time to donate to a scholarship fund

Last year, Congress passed a law that makes it more favorable for Americans to donate to charities. By increasing the SALT (State And Local Tax) deduction limits, it has now become more advantageous for many taxpayers to itemize deductions. And when you itemize deductions, you can deduct charitable contributions such as donating to a scholarship fund. Before 2025, the most you could deduct on your Federal income tax returns for the amount you paid in property tax, state income tax, and local income tax was $10,000 if you are married filing jointly. With a standard deduction of $29,200 (married filing jointly), taxpayers would have to have $19,200 in charitable deductions combined with the $10,000 SALT deductions to even reach the amount of the standard deduction. So, most taxpayers just took the standard deduction and did not get any additional tax benefit from their $5,000, $10,000, or $15,000 donations to charity.

For 2025, the SALT limit increased to $40,000 and the standard eduction is $31,500 (married filing jointly). The result is that for many Americans, particularly those with higher incomes, it is now more advantageous to itemize deductions instead of taking the standard deduction. This means that your $5,000, $10,000, or $15,000 charitable contribution to a scholarship fund is now tax deductible whereas in 2024 it likely was not. If you are in the 32% tax bracket, then donating $1,000 to a scholarship fund in 2025 is like donating $1,320 in 2024 – you’re now giving more of your donation to charity and less to the IRS.

Its about giving back

The vast majority of physicians went into medicine in order to make positive contributions to society by improving health. We can continue that by ensuring that qualified students are able to go into medicine without having to borrow at excessively high interest rates or take gap years. I regularly donate to my medical school alma mater’s class scholarship fund. I don’t get any special recognition, no one is going to name a building after me, and the students who get scholarship awards from our class fund will never know my name. I do it simply because it is important and for decades to come will help students who otherwise could not afford medical school.

January 14, 2026

In October, the U.S. Department of Education released its final rule on the Public Service Loan Forgiveness program (PSLF). The 36-page document is available online in the Federal Register. The central tenet of the rule is that it gives the Secretary of the Department of Education the ability to disqualify organizations as being eligible for PSLF if the Secretary determines that the organization has a “substantive illegal purpose”. Employees of those organizations would then no longer be able to count their years of employment toward public service loan forgiveness. This now allows the Executive Branch of the federal government to use PSLF as a weapon against hospitals and universities.

What is PSLF?

The Public Service Loan Forgiveness program was established by the U.S. federal government in 2007 under President George W. Bush as a way to help college graduates who enter a career or public service pay for college education by forgiving a portion of their student loans. The specific criteria are:

• Be employed by a federal government, state government, local government, tribal government, or qualifying not-for-profit organization.
• Work full-time
• Have federal direct student loans
• Make 120 qualifying monthly payments on the loans.

Once those criteria are met, any remaining principal and interest on the loan is forgiven. Thus far, 694,900 government workers and 305,500 workers at non-for-profit organizations have met all of the PSLF criteria and had the remainder of their student loans forgiven. The amount of loan forgiven for the average government worker was $73,100 and for the average worker at not-for-profit organizations was $82,200. Combined, 1,000,400 people have had loan balances forgiven at an average of $75,900 per person. 163,900 employees of healthcare organizations (mostly doctors and nurses) have had loans forgiven under PSLF.

Not all non-profits companies or organizations qualify as employers for PSLF purposes. Those that that are tax-exempt under Section 501(c)(3) of the Internal Revenue Code do qualify. Other non-profit organizations that devote a majority of their full-time equivalent employees to providing certain types of services also qualify. These services are: civilian service to the military, emergency management, National Guard, public safety, law enforcement, public interest law, early childhood education, public service for individuals with disabilities, public health (including physicians and nurses in a clinical setting), public education, public library, school library, school-based services, and public service for the elderly.

For physicians and nurses, this means that most public universities and most non-profit hospitals qualify as PSLF employers. Physicians can currently count their employment during residency and fellowship for PSLF purposes – there has been federal legislation proposed to no longer count residency toward the 120 loan repayment months but thus far, this legislation has not been voted on. Because most physicians do their residencies at non-profit hospitals, they can count 3-6 years of residency and fellowship toward the 10 years of required loan payments. 70% of medical students have education debt with an average of $220,000. The “One Big Beautiful Bill” now limits federal direct student loans for medical students to $200,000. Because federal direct student loan monthly payments are based on one’s income and because residents have a low income ($67,000 for a first year resident), it is very advantageous for physicians to begin paying off their direct student loans during residency since this results in a greater amount of principal that is forgiven at the end of 10 years.

What organizations will the Department of Education disqualify for PSLF?

The Department of Education’s new rule will permit the Secretary of the Department of Education to disqualify an organization if it engages in activities with a “substantive illegal purpose”. This is defined in the rule:

The activities indicative of a substantial illegal purpose include aiding and abetting violations of Federal immigration laws, supporting terrorism or engaging in violence for the purpose of obstructing or influencing Federal Government policy, engaging in the chemical and surgical castration or mutilation of children in violation of Federal or state law, engaging in the trafficking of children to another State for purposes of emancipation from their lawful parents in violation of Federal or State law, engaging in a pattern of aiding and abetting illegal discrimination, and engaging in a pattern of violating State laws.

The rule is proactive and goes into effect in July 2026. Organizations that are disqualified by the Secretary of the Department of Education have to wait 10 years to reapply as a PSLF qualifying organization unless the Secretary approves a corrective action plan for that organization.

The rule gives the Secretary of the Department of Education broad authority to determine what constitutes activities indicative of a substantial illegal purpose. Some of the criteria include:

“Chemical castration of children”. The rule defines chemical castration of children as:

• The use of puberty blockers, including GnRH agonists and other interventions, to delay the onset or progression of normally timed puberty in an individual who does not identify as his or her sex.
• The use of sex hormones, such as androgen blockers, estrogen, progesterone, or testosterone, to align an individual’s physical appearance with an identity that differs from his or her sex.
• Child means an individual under 19 years of age.

This essentially means any hospital or other organization that provides gender-affirming care to patients under age 19. It also means that physicians employed by hospitals cannot themselves provide gender-affirming care to anyone younger than age 19. By defining a child as younger than age 19 (rather than younger than age 18), the rule means that physicians at university student health clinics are not able to prescribe or refill sex hormone medications as part of gender-affirming care, even if those medications were initiated by the student’s personal (non-university) physician.

Aiding and abetting illegal discrimination. The Trump administration has taken the position that all DEI (diversity, equity, and inclusion) activities are discriminatory and thus illegal. Many hospitals and universities have had a variety of DEI initiatives and any of these could be considered as illegal by the Secretary of Education. Because the Secretary is given sole authority for determine what constitutes substantive illegal activities, the Secretary could choose to categorize transgender athletes, race or ethnic-specific college clubs, or implicit bias training programs, or race/religion/ethnicity-based scholarships as discriminatory.

Aiding and abetting violations of Federal immigration laws. Once again, the Secretary of the Department of Education has the authority to determine if an organization has violated immigration laws. Will this include schools that enroll students who are undocumented? Will it include hospitals that provide non-emergency medical care to undocumented immigrants? Will this include universities where students protest ICE activities? Will it include homeless shelters and food pantries that do not require proof of citizenship to get in the door?

Engaging in a pattern of violating state laws. This is very broad and gives the Secretary authority to disqualify organizations for any violation of a state-specific law. The rule does state that: “Organizations will not be penalized if their actions are legal in the State in which they are operating.” However, many organizations operate in more than one state. So, if a hospital organization has a hospital in Texas where abortion is illegal and has a second hospital in New Mexico where abortion is legal, will the organization be disqualified if it performs abortions in New Mexico since it also operates a hospital in Texas? The Secretary’s interpretation of this will be final.

Engaging in violence for the purpose of obstructing or influencing Federal Government policy. The current administration has already demonstrated that it has little tolerance for behaviors opposing its policies. When Sean Charles Dunn threw a Subway sandwich at an ICE agent in August 2025, he was arrested and charged with felony assault of a Federal officer. A jury subsequently found him not guilty. But next summer, if a university student throws a sandwich at an ICE agent, there will be no jury trial – if the Secretary decides that it constitutes assault, then the university could be determined to have activities of a substantive illegal purpose. The Secretary will be the sole arbitrator of whether a student protest is violent or not.

This is going to be huge…

The Department of Education states that the average amount of loan forgiveness is $75,900 per person. The new rule estimates that it will eliminate $1.616 billion in loans. This works out to 21,291 people who currently qualify for PSLF to be disqualified because they work for an organization that the Secretary of the Department of Education will disqualify. The implication is that the Department has already determined that it will be disqualifying a large number of organizations in July 2026. In looking over the definition that the new rule is using for “activities with a substantive illegal purpose”, it appears that the rule will mainly be implemented against public universities and non-profit hospitals.

The Trump administration has used similar justification for freezing Federal grants and withdrawing accreditation to effect policy and idealogical change at universities. It follows that the administration will use this new rule for disqualifying organizations for PSLF in a similar fashion. It is an extraordinarily powerful weapon, indeed. Because 70% of graduating medical students and 69% of nursing students have student loans, any hospital that becomes disqualified for PSLF will have a very, very hard time recruiting residents, attending physicians, or nurses. At particular risk are residents and nurses employed by university hospitals since any activities that happen on campus that the Secretary of the Department of Education deems to be “activities with a substantive illegal purpose” will result in those residents and nurses no longer being able to count their employment toward their 120 months of PSLF employment. Residents locked into a 3-5 year residency contract could face significant financial harm. Universities such as Harvard, Columbia, and Cornell that have already been extensively targeted by the Trump administration could be at highest risk.

Way too much power in one person’s hands

When the new rule was open for public comments, many commenters questioned how the determinations would be made and what the process for appeals would be. The Department of Education responded: “The Secretary will weigh any evidence presented showing that an organization’s activities violated any laws and make a determination if those violations rise to the level of substantial illegal purpose.” In other words, whatever Secretary of the Department of Education Linda McMahon says is the final word. There is no option for an appeal. This places enormous power in the hands of a single individual who is a political appointee not elected by the general populace.

I personally agree that there are organizations that are dangerously terroristic should not qualify for PSLF, such as the Klu Klux Klan and Al-Qa’ida. But the vagueness of the new rule now allows Secretary McMahon to decide what rises to a level of substantial illegal purpose. Normally in the United States, an action is determined to be illegal by conviction in the court system. The sixth amendment of the U.S. Constitution guarantees the right of citizens to a trial by jury for non-petty crimes. But in the new Department of Education rule, there is no court, Linda McMahon alone becomes the prosecutor, judge, and jury. And there is no court of appeals.

A changed mission for the Department of Education

The U.S. Department of Education’s official mission statement is “To promote student achievement and preparation for global competitiveness by fostering educational excellence and ensuring equal access.” The Department’s new rule on PSLF indicates that will use existing personnel to enforce the new rule and estimates an annual cost of $1.5 – $3 million per year. The rule represents a substantial departure from the Department’s stated mission and will now shift the Department’s mission to forcing ideologic and policy to eliminate “wokeness” and left-wing bias at our nation’s universities and hospitals. The Department of Education has now become a weapon to be used against any non-profit organization that the administration disagrees with.

Every physician, nurse, and resident who works at a university hospital or non-profit hospital should be afraid… very afraid.

December 24, 2026

If you ask 100 business, government, military, or academic leaders what are the most important factors in successful career development, 99 of them will include identifying a good mentor. For medicine in general and for academic medicine especially, mentors are essential in order to achieve one’s maximum potential. The reality is that most of us will have many mentors that each guide us through different facets of our careers. But there is usually one person who we can look back on and say that that individual had the biggest impact on helping us realize our career success.

The best mentors are not those who you model your own behavior from, but are those who actively guide you and advocate for you. The mentor’s actions should be with the mentee’s best interest in mind and not the best interest of the mentor. In other words, the mentor should act in a fiduciary manner.

When mentors do not act as fiduciaries

I’ve seen a lot of people who thought of themselves as mentors but were actually using those junior to them to advance their own careers rather than the junior colleagues’ careers. Here are some examples.

25 years ago, I was on a search committee for a new division director. We had narrowed the search to three finalists and invited each of them for a formal visit that included interviews with various hospital and college of medicine leaders. During my interview with him, he asked me if he was selected, whether he would be able to put his name on all manuscripts written by the members of the division. At the time, this included about 20 physicians and PhDs who collectively wrote dozens if not hundreds of papers a year. It was clear that he wanted to use the position of division director to advance his own career rather than to advance the careers of the members of the division. Needless to say, we didn’t offer him the job.

Our hospital had a quality director who always had a junior physician functioning as a quality intern. The junior physician spent months and countless hours reviewing patient charts in the analysis of a particular quality issue and then analyzing the data. The director had the junior physician prepare a PowerPoint presentation and then the director presented the findings to the medical staff leadership committee, to the Dean, and ultimately to the hospital’s Board of Trustees. In none of these presentations did the director mention the name of the physician who did all of the work and ultimately, the junior physician decided to leave academic medicine and go into a private clinical practice.

As a resident, there was an attending cardiologist whose main interest was his research laboratory. However, he was required to attend on the inpatient cardiology service 3 months a year in order to earn enough clinical income to cover his salary. He viewed the residents on the cardiology service as indentured servants whose main role was to do H&Ps, write progress notes, collect data, and put in orders. To him, residents were a tool for him to use to earn clinical income. He would show up for an hour a day to round on patients and then would go back to his research lab for the rest of the day. His belief was that residents were responsible for their own education and did little to no teaching.

When my own mentors acted at fiduciaries

As a third year medical student, I spent the month of December at a community hospital in Columbus on a general surgery rotation. At the time, students on surgery rotations were pretty low in the pecking order and were generally relegated to doing history and physical exams, collecting lab results, and performing general scut work. If a student was lucky, he or she might be granted the opportunity to stand in the corner of the operating room and watch the attending surgeon and residents perform an operation. But on the first day of December, my attending told me that he and the resident would do the H&Ps and that his nurse would collect labs and do scut. He said that I could learn the most about general surgery from being in the operating room. His goal for me was for me to scrub in on 100 surgeries during the month. He told all of the other surgeons at the hospital the plan and I held retractors during a Whipple procedure, made an incision to remove a lipoma, stood by the operating table during heart and brain surgeries, and helped suture abdominal surgery closures. I still rounded with the attending and resident every day but by the end of the month, I had been in on 100 procedures and learned more than any other month of my medical school clinical rotations.

During my first year of pulmonary/critical care fellowship, we had a weird case in our ICU of a college student who developed respiratory failure with diffuse pulmonary infiltrates and a large number of lung eosinophils found during bronchoscopy. We soon identified 3 other cases of a previously undescribed disease that we called “acute eosinophilic pneumonia”. One of my attending physicians suggested that I write it up and send it to the New England Journal of Medicine. It took me 35 drafts with the attending physician finding something to change in the first 34 but eventually we sent it in and it was accepted. The attending physician told me to put my name first on the article, rather than his name – and it launched my academic clinical career.

During the second and third years of my fellowship, I was assigned to do research with a different attending physician who specialized in the role of interleukins in lung disease. He had seen an article that suggested that some interleukins were bound to microtubules, the intracellular scaffolding that gives cells their shapes. He had me do a few experiments that supported the role of microtubules with interleukin production by a type of lung cells called alveolar macrophages. He then anointed me as the alveolar macrophage microtubule guy. That became the basis of grants I received from the National Institutes of Health and the American Lung Association – it launched my academic research career and for a few years, I was the world’s leading expert in the very obscure and esoteric field of the role of human alveolar macrophage microtubules during inflammation (mainly because no one else was doing research on it).

Fiduciary mentors put the mentee’s interests first

As a species, we physicians often have big egos that need to be constantly stroked. We have spent 15 to 20 years of training after high school competing to get into the best colleges, medical schools, residencies, and fellowships. Success in that competition usually means trying to make ourselves look better than everyone else – better test scores, better grades, more publications, more grant money, and more leadership appointments. So it is the rare physician who can step away from making themselves successful and famous to making a trainee or junior colleague successful and famous. Here are some of the specific actions that a fiduciary mentor can take for their mentees. Although these are derived from my experiences and observations as an academic physician, they can be generalized to most professions.

• Trainees are there to be trained. Whether the trainee is a resident, a PhD post-doc, or a business intern, the reason they are there is to learn. At that level, learning is by a combination of the learning triad: (1) observation of experts performing their skills, (2) practice performing those skills themselves, and (3) didactic training. A fiduciary mentor ensures that the mentee has the opportunity to do all three. The trainee is not there to simply do the senior colleague’s work for them.
• Nominate for or appoint to committees. A common warning given to junior professionals is to “protect your time” and this often translates to avoiding committee work. But whether the committee is at the hospital, university, corporate, or professional society level, committee membership can expose the junior professional to other organizational or national leaders and can be a vehicle for invaluable career networking.
• The person who does the work should be the first name on the manuscript. Too many tenured professors put their name first on any research papers that come out of their lab. This is self-promotion at the cost of their junior colleagues’ reputation building.
• Credit earned is credit due. When a medical resident is the one who figures out the perplexing rare diagnosis, the attending should publicly credit the resident with the diagnosis rather than taking credit themselves. Same with the committee chairman when a committee member performs some cost savings analysis of hospital operations. Or the research lab director when a PhD student makes some new scientific discovery.
• Share lectureships. When the fiduciary mentor is asked to give a grand rounds or other lecture, invite the mentee to be a co-presenter for the lecture. It sends the world the message that this mentee is an expert and what they have to say has value.
• Nominate the mentee for local and national presentations. Professional societies all have their own annual national or regional meetings. The fiduciary mentor nominates mentees to give presentations. For 25 years, I hosted the OSU MedNet continuing medical education webcast and I invited junior faculty physicians to be guest presenters in their chosen area of sub specialization in order to get their name out as emerging experts.
• Tailor the degree of autonomy to the level of experience of the mentee. In my outpatient clinic, I had medical students, internal medicine residents, and pulmonary fellows who rotated to work with me. Each of these three types of trainees came with different degrees of experience and required different degrees of supervision. The fiduciary mentor neither sets the mentee up for failure by giving them too much autonomy nor holds them back by not giving them enough autonomy.
• Prepare the mentee for where the field is going to be in the future, not just where it is today. Hockey legend Wayne Gretzky famously said: “I skate to where the puck is going to be, not where it has been.” This is a great lesson in any career, not just hockey. The fiduciary mentor identifies the future needs and demands in the field and prepares mentees to be the experts in those needs and demands. When our hospital was considering purchasing our first surgical robot for the operating room, our Chief of Surgery sent one of the junior general surgeons to spend a couple of weeks at a hospital that had already acquired a surgical robot. When he came back, he instantly became the go-to surgeon for robotic herniorrhaphies and cholecystectomies. Pretty soon, he was giving regional and national lectures in the then-new field of general surgery robotics.
• Foster expertise. In the research lab, the lab director should identify new side areas of research that the research fellows and doctoral students can explore and develop in order to create new areas of research that they can claim as their own in order to launch their own careers. If a junior physician has an interest in pulmonary vasculitis and there is no current expert in pulmonary vasculitis on the faculty, then figure out how to direct all of the pulmonary vasculitis consults to that junior physician’s clinic. And be sure that the physician is assigned to give pulmonary vasculitis lectures to fellows and residents.
• Listen. Too many people who think they are mentors ascribe to the old saying that “Children should be seen and not heard.” A mentor cannot be a fiduciary unless he/she listens to the mentee in order to determine what it is that they really want. 90% of internal medicine residents who apply to cardiology fellowships will say that they want to be teachers and researchers – that is what it takes in order to get into a cardiology fellowship. But most cardiology fellows eventually change their mind and actually go into private practice. And when they do change their mind, their future careers would benefit more by additional clinical training and business training rather than performing experiments in a research lab. The fiduciary mentor listens to what the mentee really wants rather than what the mentee thinks the mentor wants to hear.
• A mentor’s most valuable gift is his or her time. Few things are more impactful to a mentee than one-on-one time with their mentor. Whether that be time spent teaching a laboratory technique, demonstrating a physical examination technique, or reviewing a business document prepared by the mentee, when a mentor gives their time purely for the benefit of the mentee, a true fiduciary role is established.

The legacy of a mentor is the mentee

I carry with me a little piece of every mentor I ever had. I’ve incorporated all of their behaviors, phrases, priorities, and skills into my own persona. And I’ve passed them on to my own mentees over the course of my career. Human civilization has been built by mentors passing on knowledge and skills to their mentees and by doing so, fiduciary mentors create their true legacies.

December 1, 2025

The 2025 federal budget bill, H.R. 1, was signed into law last week. In it were provisions that limit the amount of federal student loans that medical students can take out. For many students, this will mean taking out additional private loans in order to attend medical school.

H.R. 1 (aka, the “One Big Beautiful Bill”) contains provisions in section 81001 (page 263 of the PDF version of the bill) that change the limit on the amount that students can borrow from federal direct loans. In the past, there were three types of federal direct loans:

1. Federal direct subsidized loans. These are for undergraduates with financial need and currently come with a 6.53% interest rate.
2. Federal direct unsubsidized loans. These are for either undergraduates or graduate/professional students regardless of financial need and currently come with a 6.53% interest rate (undergraduates) or 8.08% interest rate (graduate/professional students).
3. Federal direct plus loans. These are for graduate and professional students (or parents of these students) and cover educational costs that exceed the limits of the federal direct unsubsidized loans. They come with an interest rate of 9.08% (dropping slightly to 8.94% after July 1, 2025).

H.R. 1 eliminates the federal direct plus loans and puts a cap on the total amount of federal direct subsidized and unsubsidized loans that each student is eligible for. For medical students, this cap is $50,000 per year and $200,000 total. This amount is in addition to the amount borrowed for undergraduate education.

Medical school is expensive

For the overwhelming majority of students, the $200,000 cap on federal loans for medical school will not be sufficient and they will need to look for other ways to pay for their medical degree. According to the Association of American Medical Colleges, in 2025, the median total cost to attend an in-state public medical school for 4 years is $286,484. For private medical schools, that cost is $390,848. Fortunately, most students can obtain scholarships and/or financial support from their parents to pay for at least some of the costs of their medical education. As a result, only 73% of students at public medical schools and 67% of students at private medical schools have to take out loans to get through medical school. For those who do take out loans, the median amount borrowed specifically for medical school is $200,000.

On the surface, it would appear that the federal direct unsubsidized loan limit for medical school of $200,000 aligns with the median amount borrowed by medical students of $200,000. But there is danger in the use of median values because statistically, 50% of the students will borrow more than the median amount. Therefore, 37% of students attending public medical schools and 34% of students attending private medical schools will be unable to finance their medical education through scholarships, parental support, and federal direct loans. In the past, these students could take out federal direct plus loans to cover the gap between the cost of their medical education and the limit by the federal direct unsubsidized loans. H.R. 1 eliminates the federal direct plus loan program so this is no longer an option.

So, what can these medical students do?

The good news is that physicians are well-paid after completing their residencies and fellowships. Thus, student loan repayment is less of a burden for doctors than for those with other degrees. But it is hard to see that when a medical student is facing borrowing $300,000 or $400,000 to pay for 4 years of medical school and will not be getting an attending physician income until after an additional 3 to 7 years of residency and fellowship training. There are steps that these students can take:

1. Apply for scholarships. On the surface, public medical schools are considerably more expensive than private medical schools. However, many private medical schools have large endowments directed for scholarships. Thus, in some cases, it may actually be less expensive for a given student to attend a private medical school than to attend a public medical school. In addition, there are scholarships available at public medical schools that can defray the cost of education. Talk with the financial aid office of every medical school you get accepted to before making a decision about which school to attend.
2. Take a gap year to work. As I’ve written in a previous post, I am not a fan of gap years and I believe that our medical school admissions committees overvalue them. On the surface, taking a year or two between college and medical school would seem to allow a future student to earn additional money to help pay for medical school. However, medical school admissions committees are not looking for applicants who spent their gap years working as highly-paid investment bankers or software engineers. Instead, those committees are looking for applicants who spent their gap years in low-paying jobs like public health and medical research. The bottom line is that gap year earnings contribute little, if any, toward the cost of medical school.
3. Choose your medical school wisely. Without scholarships, private medical schools cost an average of just over $100,000 more than public medical schools. Too many undergraduates believe that the notoriety of a famous private medical school equates to a better education than a public medical school. But for most physicians it really makes no difference whether they attend a private or public medical school. A family medicine physician who went to Harvard Medical School is going to have pretty much the same income as a family physician who went to the Ohio State University College of Medicine. Unless that private medical school can come up with a lot of scholarships, you are probably better off going to a good public medical school in your home state.
4. Consider the military. The armed forces as well as the National Health Service Corps provide scholarships for medical students (often full-ride). For those willing to spend several years in the military or National Health Service Corps, this can be a great way to pay for medical school.
5. Consider a practice agreement. Some smaller communities will pay for some or all of the cost of medical school in return for an agreement that you will practice in that community after you complete your training. This is most commonly for those planning a career in primary care (rather than subspecialties).
6. Private loans. These often come with higher interest rates and less favorable repayment plans than federal direct loans. Nevertheless, they can cover the gap previously covered by the federal direct plus loans. These are typically available at banks and credit unions. Because of the variability in rates and terms, it is best to shop around before signing a loan contract.
7. Work part-time. Medical school is demanding and doesn’t leave much free time. However, there may be time during the summers of 1st and 2nd years, vacation months during 3rd and 4th years, and holidays to earn a little money. I was fortunate to be able to work in a research and clinical lab during my vacation time during medical school. I didn’t make a lot but it was enough to help pay the rent.
8. Get a roommate. Housing costs are a significant expense during medical school. Living with a roommate(s) can substantially reduce those costs.
9. Don’t waste money on stupid stuff. Every human needs to prepare an annual budget but medical students really, really need to prepare budgets. Do you really need to buy concert and football tickets? Is it cheaper to rent an expensive apartment close to campus so as to avoid having to pay for even more expensive parking? At Mayo Clinic, medical students are required to wear (expensive) business suits whereas at most reasonable medical schools you can get by with Dockers and a permanent press shirt.

What can physicians do?

As practicing physicians, we have an obligation to ensure that the best and brightest students enter our profession. For many potential students, the cost of medical school can pose an insurmountable barrier. There are steps we can take:

1. Contribute to scholarships. Every year, my wife and I contribute to our undergraduate and medical school alma maters’ scholarship programs. Too many physicians want to donate for a new campus building to be named after them. What our profession really needs, however, is funds to ensure that every qualified student who gets accepted to medical school can afford to attend.
2. Volunteer teach. Private practice physicians are frequently unpaid preceptors for medical students during their clinical rotations. Since retiring, my wife and I both provide many hours of pro bono classroom instruction during the OSU College of Medicine first year pulmonary module. The less medical schools have to pay for lecturers and preceptors, the less costs will have to be then passed on to students in the way of tuition fees.
3. Buy a student dinner. Many medical schools have programs for groups of students to regularly get together with attending physicians over dinner for informal mentorship. Every time you take a group of students out to dinner or have them over for dinner at your house is one less meal that they have to pay for themselves.
4. Educate your congressional representatives. The raw fact of H.R. 1 is that one-third of medical students will no longer be able to pay for medical school with traditional federal student loans. This has implications for affecting the supply and quality of physicians in the future. This will be especially true for relatively lower paying primary care physicians: family medicine, pediatrics, internal medicine, and OB-GYN. Make sure that your senators and representatives know what they just voted to do. Ideally, the federal direct unsubsidized loan borrowing limit should be raised to equal the median cost of a 4-year in-state public medical school ($286,000 in 2025). Let’s be realistic – physicians are about the least likely group to default on their student loans so at 8-9% annual interest, the federal government is not going to lose money on medical school loans in the long run.
5. Educate undergraduate advisors. Undergraduates must generally commit to a pre-med curriculum by their sophomore year in order to take the required science courses and take the Medical College Admissions Test. That decision to pursue pre-med is generally made in consultation with one of the university’s advisors, often a dedicated pre-med advisor. These advisors need to be educated about the cost of medical school but also about options for paying for medical school so that the potential great doctors of tomorrow are not dissuaded from applying.

The biggest danger…

The 2025 H.R. 1 budget bill will make it harder to pay for medical school. The biggest danger is not that doctors will not be able to find other ways to finance their education or be able to pay back their loans. Instead, the biggest danger is that promising medical school applicants will decide that attending medical school is just not worth the cost.

July 11, 2025

Last month, the National Residency Match Program released the data from the subspecialty fellowship match for physicians who will begin their fellowship training in July 2025. There is a wealth of information in the data and it tells us a lot about how young physicians see the future of medicine and a lot about what subspecialties will likely have physician shortages in the future.

Overall, there were 77 subspecialties with a total of 14,620 offered fellowship positions, of which 12,390 (84.7%) were filled. There were 14,833 applicants, of whom 12,390 (83.5%) matched to a subspecialty fellowship position. This represents a continued trend for more fellowship positions and more fellowship applicants each year. For example, in 2000, there were just 3,000 fellowship positions offered, only 20% of the number offered this year.

There are several categories of applicants including graduates from U.S. medical schools (MD), graduates from U.S. osteopathic schools (DO), Canadian medical graduates, U.S. international graduates (for example, U.S. citizens attending Caribbean medical schools), and non-U.S. citizen international graduates (e.g., foreign medical graduates). In general, U.S. MD applicants tend to be the most competitive for fellowship positions and U.S. international graduates tend to be the least competitive. I’ve grouped the data by all of the subspecialty fellowships within various specialties.

Internal Medicine

The internal medicine subspecialty fellowship match day was December 4, 2024. In all, there were 8,985 applicants for 7,169 fellowship positions. But for several subspecialties, there were fewer applicants than positions offered including adult congenital heart disease (3 fewer), advanced heart failure and heart transplant (63 fewer), geriatric medicine (178 fewer), palliative medicine (48 fewer), infectious disease (91 fewer), interventional cardiology (35 fewer), and nephrology (95 fewer). These subspecialties are considered non-competitive, since nearly all of the applicants should theoretically be able to match into a position (or at least those applicants who are reasonably competent and non-psychotic). The graph below shows the percent of available positions for each subspecialty that were filled by any applicant (blue bars) and by U.S. MD applicants (orange bars).

The most competitive subspecialties were cardiology, gastroenterology, and hematology/oncology – 100% of available fellowship positions in each of these subspecialties filled. The least competitive were heart failure/heart transplant and geriatric medicine with fewer than 50% of available positions filled. Notable subspecialties with a low percentage of positions that filled were palliative medicine (80%), infectious disease (70%), and nephrology (73%). Note that adult congenital heart disease, heart failure/transplant, cardiac electrophysiology, and interventional cardiology are sub-subspecialties since to be eligible to apply, one must first complete a cardiology subspecialty fellowship.

The popularity of a subspecialty can also be measured by the percentages of available positions that were filled by U.S. medical school (MD) graduates. By this measure, nephrology was the least popular subspecialty with only 18% of positions filled by U.S. MD graduates, followed by geriatrics with 20% filled by U.S. MD applicants, and heart failure/heart transplant with only 24% of positions filled by U.S. MD graduates.

Pediatrics

The pediatric subspecialty fellowship match day was also on December 4, 2024. In all, there were 1,667 applicants for 1,970 fellowship positions. Unlike internal medicine, in most pediatric subspecialties, there were fewer applicants than available positions. Only two subspecialties had more applicants than positions: pediatric critical care and pediatric hospital medicine. The implication is that most (reasonably competent) applicants who wanted a pediatric subspecialty position were able to get one somewhere.

The most competitive pediatric subspecialties were critical care (99% of positions filled), pediatric transplant hepatology (93% of positions filled), cardiology (92% of positions filled), and pediatric hospital medicine (92% of positions filled). The least competitive were child abuse and nephrology with fewer than 40% of available positions filled. As measured by the percentage of available positions filled by U.S. MD graduates, child abuse and nephrology were again the least competitive, with fewer than 24% of positions filled by U.S. MD graduates.

Not included in the above graph is the very small subspecialty of academic pediatrics with only 5 available positions and 6 total applicants nationwide.

Surgery

The surgical subspecialty matches were held on different days between May and October 2024. It is important to note that there are two pathways for thoracic surgery and vascular surgery with positions available both as a integrated residency pathway (5 years for vascular and 6 years for thoracic) or as a 2-3 year subspecialty fellowship after four years of general surgery. The data below is only for the thoracic and vascular surgery subspecialty fellowship pathway.

Three surgical subspecialties had fewer applicants than available positions: hand surgery (25), surgical critical care (47), and vascular surgery (2). Surgical subspecialties were considerably more competitive than either internal medicine or pediatric subspecialties. All surgical subspecialties filled more than 80% of available positions with four subspecialties filling 100% of positions (colo-rectal, pediatric, oncology, and thoracic). Similarly, when measured by the percentage of available positions filled by U.S. MD graduates, all surgical subspecialties were competitive and filled with more than 50% U.S. MD graduates.

Obstetrics and Gynecology

The OB/GYN subspecialty match day was September 25, 2024. There were 526 applicants for 464 available positions in seven subspecialties. Two subspecialties had fewer applicants than available positions: complex family planning and maternal-fetal medicine.

Three subspecialties filled 100% of available positions: pelvic medicine & reconstructive surgery, gynecologic oncology, and minimally invasive gynecologic surgery. Overall, the OB/GYN subspecialties were all very competitive with all of them filling 90% or more of their available positions and all of them filling 74% or more with U.S. MD graduates. Maternal-fetal medicine was the least competitive of the OB/GYN subspecialties.

Radiology

There are 5 radiology subspecialties and their match day was held on June 12, 2024. In all five, there were fewer applicants than available positions, implying that just about any (reasonably competent) radiology resident was able to find a subspecialty fellowship position somewhere.

Emergency radiology was the least competitive subspecialty with only 37% of available positions filled in total and only 11% filled with U.S. MD graduates. However emergency radiology is a relatively small subspecialty with only 37 fellowship positions offered this year. Interventional radiology was the next least competitive with only 62% of available positions filled in total and only 30% filled with U.S. MD graduates.

Neurology

There are 4 subspecialties in neurology that held their match days between May and August 2024. In two subspecialties, there were fewer applicants than available positions: epilepsy and vascular neurology.

Emergency Medicine

The four emergency medicine subspecialties held their match day on October 30, 2025. In both the subspecialties of clinical ultrasound and emergency medical services, there were fewer applicants than available positions. These two subspecialties also filled with the lowest percentage of U.S. MD graduates (41% and 43% respectively).

Physical Medicine & Rehabilitation

There are 4 subspecialties in PM&R that held their match days in either October or December 2024. In all four subspecialties, there were fewer applicants than available positions implying that nearly all applicants would theoretically be able to find a position somewhere in the country. The least competitive subspecialties were pediatric rehabilitation medicine with 46% of available positions filled (25% by U.S. MD graduates) and spinal cord injury rehabilitation with only 38% of available positions filled (21% by U.S. MD graduates). Overall, the demand for subspecialty training in physical medicine & rehabilitation appears to be considerably less than in other specialties.

All of the Rest

There were several specialties with only one or two subspecialties that participated in the subspecialty match. Their match days ranged from May 2024 to January 2025, depending on each subspecialty and their results are shown in the graph below.

In two of the miscellaneous subspecialties, there were more applicants than available positions (allergy & immunology and sports medicine). These two subspecialties were also the most competitive with 99% of available positions filled in the match. In all of the others, there were fewer applicants than available positions. The least competitive was medical genetics with only 51% of positions filled in total and only 16% filled by U.S. MD graduates. Laryngology is a relatively small subspecialty of otolaryngology with only 12 available positions nationwide – of these, 6 (50%) were filled in total.

Implications of the Subspecialty Match

There are several conclusions we can draw from this years subspecialty match:

• If you are a resident in pediatrics, radiology, physical medicine, or psychiatry and you want a fellowship, you can usually get one. In these specialties, most or all of the subspecialties had fewer applicants than available positions. Numerous subspecialties of other specialties also had fewer applicants than positions. However, applicants must have already completed 3 to 4 years of residency after 4 years of medical school making all subspecialty applicants in their late 20’s or early 30’s. Physicians in this age range tend to be less mobile because of spouses with jobs or children in school. Thus in theory, any reasonably competent resident in one of these specialties should be able to match to a subspecialty fellowship somewhere, but in reality, they may not be able to match to a program that is geographically feasible for them.
• Foreign medical graduates are increasing. Non-U.S. citizen international medical graduates (foreign medical graduates) must normally first complete a residency in the United States before being eligible to apply to a U.S. subspecialty fellowship. The COVID pandemic caused a significant reduction in the number of foreign medical graduates applying to the residency match. This resulted in fewer foreign medical graduates in U.S. residencies and thus fewer foreign medical graduates in those U.S residencies to apply to subspecialty fellowships. This year, the total number of foreign medical graduates significantly increased, reflecting the rebound in foreign medical graduates in U.S. residencies over the past 3 years. Overall, 75% of foreign medical graduates were able to match into a subspecialty fellowship, making them more competitive than U.S. citizens who attend international medical schools (69% of whom matched) but less competitive than U.S. DO graduates (82% of whom matched), or U.S. MD graduates (91% of whom matched). The subspecialties with the highest percentage of available positions filled by foreign medical graduates were medical genetics (55%), endocrinology (39%), nephrology (36%), interventional cardiology (34%), and rheumatology (34%).

• Nephrology is unpopular. This year’s subspecialty match has continued an alarming trend for nephrology in both pediatrics and internal medicine. As in recent previous years, a large number of nephrology positions went unfilled. Of those positions that did fill, the majority of them were filled by applicants trained in medical schools outside of the United States as either U.S. citizens or citizens of foreign countries. There are several reasons why nephrology is an unpopular subspecialty as I have discussed in previous blog posts. But the implication is that the demand for nephrologists will significantly exceed the supply of nephrologists in the future. Hospitals would be well-advised to make efforts to recruit and retain nephrologists now in order to ensure that they have adequate nephrology expertise in the upcoming years. This may mean paying more competitive salaries or training advanced practice providers to oversee some nephrology services amenable to algorithm-based management, such as dialysis and management of patients with chronic kidney disease.
• Geriatrics is unpopular. It is no surprise that geriatrics is an unpopular subspecialty. It is listed in the graph above as a subspecialty of internal medicine but applicants are eligible by completing a residency in either internal medicine or family medicine. The unpopularity of geriatrics is primarily financial. Geriatric specialists have incomes equal to or lower than either general internists or family physicians. Thus, there is no financial incentive for internists or family medicine physicians to spend an extra one or two years of fellowship training to become a geriatrician. Moreover, general internists and family physicians are normally credentialed to care for geriatric patients, without needing to have subspecialty geriatric training.
• Endocrinology is unpopular with U.S. medical graduates. In the past, endocrinology has had a high percentages of unfilled positions. This year, 98% of positions filled but the majority were by international medical graduates – either U.S. citizens or citizens of other countries who attended medical school outside of the United States. Endocrinology continues to be unpopular with U.S. MD graduates with only 30% of available positions filled by U.S. MD graduates.
• Infectious Disease is unpopular. In both internal medicine and pediatrics, infectious disease also remains an unpopular subspecialty. Similar to geriatrics, infectious disease specialists often have incomes less than the incomes of general internists or general pediatricians. This results in a strong financial disincentive to spend an additional 2 years of subspecialty fellowship training just to make less than one could have if they went into clinical practice straight out of residency. The current anti-vaccine rhetoric among many political leaders has left many infectious disease specialists feeling maligned and frustrated.
• Surgical subspecialties are highly competitive. The surgical subspecialties filled all or nearly all of available positions. Furthermore, more than half of all of these positions were filled by U.S. MD graduates. Critical care surgery was the least competitive with fewer total applicants than available positions and with just 83% of positions filled. There is no separate trauma surgery fellowship and most trauma surgeons complete a critical care surgery fellowship instead. This implies that there could be a shortage of trauma surgeons in the future.
• Maternal-fetal medicine and complex family planning are becoming unpopular. Two OB/GYN subspecialties that are affected by abortion laws warrant discussion: complex family planning and maternal-fetal medicine. Physicians specializing in complex family planning often perform abortions for women with high-risk medical conditions. Physicians specializing in maternal-fetal medicine perform deliveries for women with high risk medical conditions and often advise these women to have abortions because of the risk of maternal death during delivery. Many physicians in these two specialties have been leaving states that passed laws restricting abortion. Complex family planning as a OB/GYN subspecialty was notable because prior to 2024, all of its subspecialty fellowship positions filled each year. Last year, there were 3 unfilled positions and this year, there were 2 unfilled positions. Maternal-fetal medicine was also notable because among OB/GYN subspecialties, it had the fewest positions filled with U.S. MD graduates at 74%. This year, there were 16 unfilled positions in maternal-fetal medicine whereas last year, there were no unfilled positions and there was only 1 unfilled position in each of the 2022 and 2023 matches. The number of applicants to maternal-fetal medicine fellowships has dropped from 170 in 2022 to 151 this year. This suggests that OB/GYN residents perceive these two subspecialties as being vulnerable to restrictions and/or sanctions, making them less desirable than in the past. It also implies that there will be fewer obstetricians trained in managing high-risk deliveries than in the past, particularly in those states that have laws banning abortion.
• We are training fewer interventional radiologists. For the past 5 years, the number of fellowship positions and fellowship programs in interventional radiology has been falling. In 2022, there were 83 programs offering 166 positions; today, there are only 73 programs offering 159 positions. In 2022, 154 applicants matched in interventional radiology, this year, only 93 applicants matched. This indicates that we are training fewer interventional radiologists than in the past. However, the need for interventional radiologists is still quite high and consequently, we will likely see worsening shortages of them in the near future.
• Allergy & immunology continues to be competitive. Applicants can either complete a pediatric or an internal medicine residency to be eligible for an allergy & immunology subspecialty. Overall, 99% of available positions filled and most were by U.S. MD graduates.
• Sports medicine is competitive. To be eligible to apply to sports medicine, an applicant can have completed a residency in either family medicine, internal medicine, pediatrics, emergency medicine, or physical medicine & rehabilitation. Overall, 99% of available positions filled. Sports medicine is particularly popular for U.S. DO graduates who accounted for 41% of filled positions.

The demand for a particular subspecialty fellowship depends primarily on how residents perceive the lifestyle and income of that subspecialty. For example, allergy & immunology has a highly desirable lifestyle with most allergists working weekdays and little weekend or night call duties. On the other hand, geriatrics is unpopular because geriatric physicians generally have a lower income than general internists while incurring the cost of an additional 1-2 years of training.

The results of the match tell us a lot about which subspecialties are popular or unpopular with residents. These results also tell us about which subspecialties are likely to have physician shortages in the future. Successful hospitals will anticipate these shortage subspecialties and make efforts now to secure adequate staffing in these subspecialties with younger physicians who will be able to provide these needed subspecialty services for years to come.

March 10, 2025

A couple of months ago, I was talking to one of our graduating medical school senior students. He told me that he had applied to 35 different internal medicine residency programs. That may seem like an astoundingly high number but it is not. Over the past 30 years, there has been steady application inflation, that is, senior medical students are applying to more and more residency programs each year. In the 1980’s, residency applications were submitted on paper with each program having a different application template. In the 1990’s, personal computers made it increasingly easy for applicants to generate multiple residency applications. In 2005, the ERAS system (Electronic Residency Application Service) made it easy to apply to a large number of residencies electronically by creating one, single standardized residency application that was accepted by all residency programs. In 2020, residency interviews went virtual making it cheaper and easier for applicants to interview at large numbers of residencies. The result is that students are applying to more residency programs and doing more interviews for residency than ever before.

In 1992, when students applied by filling out paper application forms, the average number of residency applications was 12 per applicant. By 2007, after the introduction of ERAS, that number grew to 30 applications per applicant. Once residency interviews went virtual due to COVID, it grew to an average of 71 applications per applicant in 2021.

Application inflation is harmful to both the applicants and the residency programs. ERAS charges applicants by the number of applications they submit: $11 per application for the first 30 and $30 per application for any applications over 30. For the residency programs, application inflation adds time and expense to read through hundreds or even thousands of applications. This can result in the program wasting the faculty members’ time reviewing applications and virtually interviewing applicants who really have no interest in the residency program. It also can result in residency programs making an initial cut of applicants based on easily quantifiable metrics such as the perceived quality of the applicant’s medical school, their STEP 1 and STEP 2 exam scores, or their rank in their medical school class. These metrics do not always predict how good of a doctor the individual will be after completion of residency, however.

Application inflation has gotten out of control

The Association of American Medical Colleges (AAMC) publishes statistics on the ERAS each year. Data from the 2024 residency match is now available. The graph below shows the number of internal medicine residency applications per applicant since 2019, subcategorized by medical school graduates (MD), osteopathic school graduates (DO), and international medical school graduates (IMG).

The number of residency programs that each applicant applies to also varies by specialty with applicants to highly competitive specialties applying to more programs than less competitive specialties. The graph below shows the average number of residency applications per applicant by specialty in 2024 for medical school graduates (MD) and for all categories of applicants combined (MD, DO, and IMG applicants).

There is a much larger variation in the number of applications that residency programs in each specialty receive. Internal medicine residency programs receive the largest number of applications, averaging 3,165 applications for each internal medicine residency program. This number is so high because internal medicine has the largest total number of applicants each year and has the largest total number of available residency positions.

Applicants do not interview at all residency programs that they apply to. After they submit their application, the residency program will decide whether or not to offer the applicant an interview. Applicants then decide whether or not to interview at each program that offers them an interview. Last year, the median number of interviews per residency applicant was 14 but there was a lot of variation between different specialties.

The solution to application inflation is signaling

Residency applicants can now “signal” their strong interest in a limited number of residency programs as a way of communicating to those programs that they would be more likely to rank the program high on their residency match rank list. Most (but not all) specialties offer program signaling. These program signals are listed on the ERAS application that the applicant fills out in the fall. This allows the residency programs to weed out those applicants who are unlikely to consider their residency program and can help the residency program to prioritize those applicants who are truly interested in the residency program for interviews.

During the COVID pandemic, otolaryngology was the first specialty to offer signaling during the 2021 residency match year. Analysis of ENT match data from that year found that applicants were significantly more likely to receive an interview from signaled programs (58%) versus non-signaled programs (14%). The success of the signaling innovation in ENT in 2021 resulted in signaling rapidly spreading to other specialties.

Each specialty decides if and how many signals will be accepted in the upcoming ERAS applications. Programs can also stratify signals as being “silver” (interest) or “gold” (very high interest). For the upcoming residency application season that begins this fall and will culminate in the 2025 residency match in March 2025, the following are the numbers of signals agreed upon by each specialty.

How will residency programs use signals?

Individual residency programs must publicize how they will use applicant signals in July, prior to students submitting their ERAS applications. The Alliance for Academic Internal Medicine recommends that internal medicine residency programs choose from the following three recommended wordings to communicate how they will use signals:

• “Due to a high volume of applications, we [do not]/ [are very unlikely to] extend interview offers to applicants who do not signal our program.”
• “While we preferentially review applications from those who signal our program, we also consider applicants who do not signal us.“
• “Our program does not consider signals in our interview offer decision-making process and review applicants equally whether or not they have signaled us.”

Because internal medicine residency programs receive thousands of applications, it is anticipated that many programs will opt to only interview applicants who send them a program signal. Residency programs are advised to not use the presence or absence of a signal in devising their rank list but rather to determine which applicants to interview and then create their match rank list after interviews are completed.

How should applicants use signals?

Applicants who apply to a specialty that does accept program signals should use all of their signals. If a specialty categorizes signals as gold and silver, then the applicant’s top choices should be gold and next choices silver. Because many residency programs are likely to only interview those applicants who send them a program signal, applicants should spread their signals between their “reach” programs and their “safety” programs based on their self-assessment of their competitiveness. Although sending a program signal may increase the likelihood of getting an interview, it does not guarantee an interview; therefore applicants should not waste their signals on residency programs that they are clearly not qualified for.

Applicants should use their signals for residency programs at their home (medical school) institution, institutions that they have done away clinical rotations, and institutions that they have not experienced during their medical school training. If a residency program clearly states that it does not use signaling to decide who to interview, then applicants should not waste a signal on that residency program and instead use it for another residency program.

Applicant geographic preferences

In addition to sending a signal to express interest in a particular residency program, applicants can specify geographic regions that they prefer on the ERAS application. Residency programs may also use these stated geographic preferences in selecting which applicants to offer interviews. Applicants can chose up to 3 of the following U.S. census regions:

• Pacific: AK, CA, HI, OR, WA
• Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
• West North Central: IA, KS, MN, MO, NE, ND, SD
• East North Central: IL, IN, MI, OH, WI
• West South Central: AR, LA, OK, TX
• East South Central: AL, KY, MS, TN
• South Atlantic: DC, DE, FL, GA, MD, NC, PR, SC, VA, WV
• Middle Atlantic: NJ, NY, PA
• New England: CT, ME, MA, NH, RI, VT

Applicants can also express their preference for residency programs located in urban versus rural areas. Like geographic preferences, applicants do not have to specify rural or urban if they have no preference. A sample ERAS application can be found here.

How important are signals to residency program directors?

The AAMC surveyed residency programs directors after the 2024 match to determine what factors are highly considered when deciding whether or not to offer applicants an interview. Overall, the response rate was 28% (1,422 programs). Factors that program directors ranked as important or very important were:

• Step 2 exam results (75%)
• Letters of recommendation (75%)
• Personal statements (74%)
• Medical Student Performance Evaluation (70%)
• Program signals (67%)
• Geographic signals (58%)
• Selected experiences (56%)
• Meaningful experiences (55%)
• Medical school attended (54%)

Factors that fewer than half of residency program directors rated as important or very important included: standardized letters (41%), meaningful experience essay (40%), medical school reputation (38%), focus areas experiences (37%), other impactful experiences essay (37%), key characteristic experiences (34%), total publications (27%), first author publications (25%), rural vs. urban preference signal (25%), Gold Humanism Honor Society (25%), MD vs DO degree (24%), Alpha Omega Alpha membership (23%), and journal reputation of publications (17%).

Of those residency programs that offered gold and silver signals, 69% of program directors considered gold signals as more valuable than silver signals in deciding which applicants to interview. Additionally, 74% of program directors reported that the program signals allowed them to identify applicants that they would otherwise have overlooked.

Next up… interview caps

The inevitable consequence of application inflation is interview inflation. That is, applicants interviewing at more and more residency programs each year. This adds even more cost, especially to the residency program that must dedicate hundreds of hours of uncompensated faculty time to perform the interviews. There is an educational cost to applicants who must take time out of clinical rotations to interview. Additionally, if interviews are performed in-person, there is a cost to the applicant of travel and lodging.

In 2020, ophthalmology instituted a limit of a maximum of 20 interviews permitted per applicant. In subsequent years, this number was decreased to 18 and then 15 interviews per applicant. For 2024, the Alliance for Academic Internal Medicine has recommended a 15 interview cap on the number of interviews each applicant can undertake. This will equal the total gold + silver signals that internal medicine applicants are permitted to utilize.

So, are program signals good or bad?

No medical student wants to be one of the residency applicants in their class that do not match. That can mean taking a year off after medical school in order to try to match the next year, settling for an undesired residency program that did not fill in the regular match, or switching to a different specialty to pursue residency. The ease of the on-line standardized ERAS application plus the advent of virtual interviews brought on by the COVID pandemic has fueled application inflation and interview inflation. Overall, I believe that program signaling is beneficial to both applicants and residency programs.

Because it is so new, program signaling is a work in progress and will undoubtedly evolve in different specialties over the next several years. But the first iterations are good and should help reel in escalating interview costs. Signaling will also cure applicants of the misconception that “more is better” when it comes to residency applications and interviews. The data from the last round of residency interviews suggest that the program signals and the geographic signals are valued highly by residency programs. However, the urban versus rural signals are of considerably less importance.

July 28, 2024

In the past, most medical students went straight from undergraduate college to medical school, without taking any time off. Now, most medical students take one or more “gap years” between college and medical school. Gap year advocates argue that this results in more mature medical students and medical school applicants with more research, volunteer hours, and work experience that makes them more competitive versus applicants who are college seniors. However, there is a downside to gap years – they reduce the nation’s overall supply of doctors by shortening the number of years doctors actively practice clinical medicine before retirement.

How many medical school matriculants take a gap year?

First, a couple of definitions. A person who applies to medical school is an applicant. An applicant who gets accepted into a medical schooling then enrolls in that medical school is a matriculant. Nationwide, for the current medical school class that began in 2023, there were 52,577 applicants and of these, 22,981 were accepted into medical school (44% acceptance rate).

The most accurate data about U.S. medical school matriculants comes from the Association of American Medical Colleges (AAMC). In 2018, the AAMC stopped reporting the age of medical school matriculants. They did report that in 2023, 3% of medical school matriculants were over age 30 years old. The AAMC does report data from its Matriculating Medical Student Questionnaire; 66% of matriculating medical students responded to this questionnaire in 2023. The data indicated that 73% of matriculating medical students were older than age 23 years. In contrast, if a person went straight from high school to college and then straight from college to medical school, that person would be 21 or 22 years old.

The Questionnaire data also indicates that 73% of the medical students reported taking at least 1 year between college graduation and medical school; 48% reported taking between 1 and 2 years; 16.5% reported taking 3 to 4 years, and 8.7% took 5 or more years off.

Advantages of the gap year

The single most important advantage of the gap year is to improve one’s résumé. Medical school admissions committees value research, volunteerism, and experience in applicants. Just having good college grades and a good MCAT (medical college admission test) score is no longer enough to get into medical school. Having one or more gap years allows the applicant to do research, volunteer, and get job experience that can make their medical school application look stronger than it would straight out of college.

Indeed, the Matriculating Medical Student Questionnaire data indicates that of matriculants who took a gap year, 52% worked at another career and 49% obtained research experience. In addition, 16% took pre-medical school classes and 21% went to graduate school (note that these percentages add up to more than 100% because some matriculants reported doing more than one thing during their gap year).

Some have argued that no one should start medical school until age 28, allowing applicants to work for a few years and build up savings to afford medical school. In fact, 40% of matriculants reported that they took the extra year(s) to improve their finances before starting medical school.

The societal cost of the gap year

The problem with the gap year is that it delays entry into the physician workforce and reduces the number of years that physicians work before retirement. The result of this is a net reduction in the supply of physicians in the U.S.

Physicians are already older on average than the typical American worker. The average age of a practicing physician in the U.S. is 53.9 years old whereas the average age of all workers in the U.S. is 41.8 years old. These numbers are not surprising since it takes a minimum of 11 years of education after high school to become a practicing physician and depending on the specialty, it can take as much as 15 years of post-high school training before entering the physician workforce. Thus, a pediatrician, family physician, or general internist will finish their residency at age 28 or 29 without taking a gap year. Add in a chief residency year and 3 years of subspecialty fellowship training and workforce entry increases to age 32 or 33 without a gap year.

The average American worker retires at age 62. Thus, the average American with a high school education will have a career length of 44 years; those with a college education will work for 40 years. The average American physician retires a few years later at age 65. Without doing a gap year, a physician with a 3-year residency will work an average of 36 years and a physician with 7 years of residency and fellowship training will work an average of 32 years. There is no reason to think that physicians who take gap years will retire at an older age than other physicians, thus every gap year will shorten a physician’s working years by 1 year. For primary care physicians (pediatrics, family medicine, internal medicine), that results in a 2.7% decrease in career span for each gap year. For specialists, it results in a 3.1% decrease in career span for each gap year.

In other words, each gap year will result in a decrease the U.S. supply of primary care physicians by 2.7% and decrease the supply of specialty physicians and surgeons by 3.1%.

What about nurse practitioners and physician assistants?

Nurse practitioners (NPs) and physician assistants (PAs) have only achieved prominence in healthcare delivery over the past 20 years so we do not have good data on the average retirement age for NPs and PAs but let’s assume it is similar to physicians at age 65 years old. Both NP and PA training takes 7 years after high school. To become a PA, you must complete 4 years of college, followed by a 27-month PA master’s program. To become an NP, you must complete 4 years of college to obtain a BSN degree, work as a registered nurse for 1 year, and then complete 2 years of NP training. Therefore, a PA or NP can enter the workforce at age 24 or 25 which is 4 years earlier than a primary care physician and 7-8 years earlier than a specialist physician.

The U.S. Bureau of Labor Statistics reports that the average NP in the United States makes $128,000 per year; The average PA income is similar. The average family physician’s income is $240,000. Looking at average in-state tuition costs at public schools, average resident salary, and average RN salary (for the required 1-year post BSN work prior to NP school), we have the following costs and incomes:

• Family Physician
  • Medical school: – $52,500 per year
  • Residency salary: + $58,500 per year
  • Income after training: + $240,000 per year
• Physician Assistant
  • PA school: – $18,000 per year
  • Income after training: + $128,000 per year
• Nurse Practitioner
  • RN salary: + $60,000 per year
  • NP school: – $9,000 per year
  • Income after training: + $128,000 per year

By putting all of these numbers together, it takes a family physician an average of eleven years after completing college to break even with an NP or PA, factoring in the cost of training and the average annual incomes. Every pre-medical school gap year increases the number of years it takes a physician to break even with net total income compared to an NP or PA. By retirement at age 65, the average family physician will have earned a net of $9 million over a lifetime after factoring in the cost of training. The average NP or PA will have earned a net of $5 million. Every gap year also decreases the total lifetime earnings of that physician. Note that these numbers do not take into account the effect of inflation on incomes but assuming that physician/NP/PA incomes increase in proportion to the cost of living, their relationships would remain similar.

In other words, every gap year demanded by medical schools increases the desirability of becoming a nurse practitioner or physician assistant versus becoming a physician. This is especially true when non-monetary advantages of NPs/PAs are considered such as shorter work weeks, less night call, and less administrative tasks.

The short-sighted view of medical school admissions committees

To get into medical school, you have to be ranked highly by the medical school’s admission committee. The number one job of those committees is to produce a first-year medical school class that looks as good as possible on paper. And there is no question about it… gap years make applicants look better on paper. But I believe that our medical school admission committees’ infatuation with gap years is failing the U.S. as a society – here is why:

The argument that gap year applicants are more mature. This is often cited by medical school admission committee members. In fact, some medical schools refer to gap years as “growth years”. Well, of course they are more mature – an applicant who does one gap year has been an adult for 25% longer than an applicant applying during the senior year of college. But I would argue that what is important is not the maturity of the first year medical student but is rather the maturity of the final product, that is after completion of residency or fellowship 7 to 11 years after starting medical school. I know of no data showing that a physician completing fellowship training at age 34 has significantly more maturity than at age 33.

The research argument. Performing research prior to medical school has become almost a prerequisite for getting into medical school. My own institution, the Ohio State University, boasts that 99% of this year’s entering medical student class performed research before applying. Our country’s medical school admission committees are largely composed of the medical schools’ faculty and research is a critical metric in assessing faculty performance. So, the committee members transfer that need for research in their own jobs to a need for research in applicants for medical school. But here is the thing: only 1.5% of all U.S. physicians actively perform research and the other 98.5% of all U.S. physicians are not involved in research, their focus is on clinical medicine. So, why are we demanding our medical students take a gap year to do research knowing that only a tiny minority of them will do research once they finish training?

The community service argument. Another checkbox on many medical school admission committees’ application review is whether or not the applicant has volunteered to do community service. I think this falls under the category of “Sounds good but no data”. In theory, doing a lot of community service can show that a person is motivated to help people and not purely motivated by the high personal income of physicians. But how much community service is enough? Consulting firms recommend applicants have 150 hours of community service. On the surface this sounds great but those 150 hours come at a time cost. For the undergraduate student who is struggling to pay tuition and has to work part-time during college, extra hours spent doing community service are hours often taken away from studying for classes. Same for the undergraduate student who is working in a research lab because she or he perceives that research is an absolute prerequisite for getting into medical school. Volunteering costs time and time equates to money; my fear is that community service requirements can become an obstacle for lower income applicants whose families cannot afford to support them while they do hundreds of hours of unpaid volunteer time instead of studying or working to pay for their tuition bills.

The “improve your financial picture” argument. 40% of medical school matriculants who took a gap year cited the need to improve their finances before staring medical school. This is understandable with the average cost of an undergraduate degree from a public college being $109,000 and from a private college being $235,000. Add in the cost of medical school at $268,000 for a public medical school and $364,000 at a private medical school and it is not surprising that medical school applicants often feel like they need to work for a few years to pay for their education. But I believe that this is a false argument. The average income the first year after a bachelor’s degree is $68,000 whereas the average family physician (a low-income physician specialty) is $240,000. By taking a gap year, applicants will be shortening the number of years worked as a physician before retirement. In the long run, you are far better off taking a low interest education loan and going straight to medical school than taking a gap year and reducing the number of years you work as a physician.

The “improve your MCAT score” argument. The AAMC cites this as a valid reason to take a gap year, along with taking additional courses to improve your grade point average. And it is true that if you take a year off after college to study for the MCAT, you are very likely to score higher on the MCAT. But does that higher score after a year of MCAT study mean that you will be a better doctor? I think not… it just means you got a higher score on the admissions test. If the MCAT is so critically important, then perhaps if our medical school admissions committees cut back on the amount of time applicants have to do research and community service, then they would have time to study more for the MCAT while they are still in college.

Admission committees need to reset their priorities

It is clear that gap years make applicants look better on paper but it is not clear that gap years make better doctors at the end of residency and fellowship. It is also clear that gap years reduce the number of years that physicians are actually practicing medicine and this reduces the supply of physicians. The requirement of gap years also makes an alternative career as a nurse practitioner or physician assistant increasingly appealing to those just beginning to plan their education.

The result of most medical students taking gap years before starting medical school is that the deans of our colleges of medicine can boast about the qualifications of their first year medical school classes. But it is a hollow boast and in the end, it is American society that is paying a price for gap years by reducing the supply of practicing physicians.

We need to stop sending undergraduate students the message that they cannot get into medical school unless they take one or more years off after college. Gap years should not be a requirement for admission.

July 12, 2024

In the “before times”, all interviews for residency and fellowship positions were performed in-person. Then came COVID when in 2022, 94% of programs offered virtual interviews exclusively and an additional 4% of programs performed more than three quarters of interviews virtually. With the pandemic fading, programs are facing the decision of whether to return to in-person-only interviews. There are compelling reasons why they should not.

The advantages of the in-person interview

I have interviewed hundreds of students applying to residency and residents applying to fellowship. As a faculty member who served for many years on our internal medicine resident selection committee and our pulmonary and critical care fellow selection committee, I believe that in-person interviews are usually preferable to virtual interviews.

For the interviewer, you get better information about the applicant’s communication skills, both verbal and non-verbal. It is also insightful to observe how the applicants interact with other applicants being interviewed on the same day and how applicants interact with the non-physician members of the office staff. The in-person interview day usually includes a lunch or dinner with some of the current residents or fellows – this is a time when applicants often reveal more of their true personality and behavior. All of these observations can impact how high an applicant is ranked on the program’s match list.

For the interviewees, an in-person interview is an opportunity to see what the facilities are like. This can include the layout of the hospital(s), inpatient rooms, outpatient clinic sites, the educational facilities, the call rooms, the library, and even the cafeteria. The applicant can get a better idea of how the current residents interact with each other, with the faculty, and with the hospital staff. One of the most overlooked advantages of in-person interviews is the opportunity to talk with other applicants being interviewed on the same day – they can often provide first-hand knowledge of other training programs and that knowledge can help an applicant decide which additional programs to interview at (or not interview at).

But in-person interviews are costly

The main disadvantage of in-person interviews is the cost – both to the applicant and to the residency (or fellowship) program. For the applicant, the time cost of each interview is considerable. To interview at a residency program within a 2-3 hour drive requires a full day to drive to that program, interview, and drive back home. To interview at a residency program farther away, it can take 2 or 3 days when factoring in travel time. This means that the senior medical student must either make arrangements to be absent from their clinical rotation for that time period or to schedule a vacation month and try to fit as many interviews into that month as possible. In addition to the time cost, there is considerable financial cost for each interview. The travel costs for interviews that the applicant can drive to are relatively low but for those interviews that require an air flight to reach, costs can add up quickly. This is especially true if an overnight hotel stay is necessary. For many applicants, there is a wardrobe cost – medical students who have been wearing kakis or scrubs with a white coat for clinic rotations for the past couple of years need to buy one or two sets of business wear for interview days. To successfully match to a residency program, students must interview at an average of 14 programs, costing them thousands of dollars in travel and wardrobe expenses. Because 71% of medical students owe debt on educational loans (with the average amount of those loans about $200,000), most students have to take out additional loans just to go to in-person interviews.

Interviews are also expensive for residency programs. A staff member must be dedicated to chaperone the interviewees and coordinate all of their schedules. Programs must usually pay for a lunch and/or dinner for the interviewees. Many programs will also cover the cost of a hotel room for interviewees traveling from out of town.

The greatest advantage of virtual interviews

In the past, here at the Ohio State University, we did not get a lot of residency applicants from students at west coast medical schools – it was just too costly for them to travel to Columbus to interview. An interview generally would require three days for a west coast medical student – one to fly to Columbus, one to interview, and one to fly back to the west coast. Instead, most of our applicants came from midwestern medical schools where applicants could drive to Columbus – often making the roundtrip drive on the same day as the interview.

For residency programs, the greatest advantage of virtual interviews is that they give you access to a larger pool of applicants. This allows the program to be more selective about the applicants that the program decides to offer interviews to and rank on the program’s match list. For some residency programs, this can mean interviewing more students with high medical school grades or test scores. For other programs, it can mean interviewing more students who fit best into the residency program. As an example, some residency programs emphasize didactic teaching whereas others emphasize more hands-on autonomy in patient care. One applicant may thrive in a residency program with a lot of lectures and research opportunities whereas another applicant may thrive in a residency program that requires residents to function more independently in patient care.

For applicants, the greatest advantage of virtual interviews is that they improve the chance that you get into a residency program that you will be happy and successful in. The most important factor in choosing a particular residency program is whether that program will allow you to reach your greatest potential as a doctor. In turn, that requires two things: the program must match your preferred method of learning and you have to enjoy being around the people that you work with. To learn any skill requires a combination of three things: observing experts, didactic education, and practice. For example, to learn how to golf requires watching how golf pros play the game, taking golf lessons, and then getting on the course and practicing. Medicine is the same but each of use has our own personal optimal ratio of observation to didactic education to practice. Finding a residency program with that offers a similar ratio of these three to your personal optimal ratio is the key to reaching your potential. The residency program that is optimal for one student may not be optimal for another student. But no matter how well a residency program fits your mode of learning, if you do not like the people that you are working with, you can never reach your fullest potential. Using virtual interviews allows the student to expand the geographic area of residency programs they consider and increases the chance of finding programs that best match the student’s preferred mode of learning, that has other residents the student enjoys being with, and has faculty that the student would like to have as mentors.

My recommendations

For residency programs: When feasible, do in-person interviews – you will get more information about an applicant than you can by a virtual interview. But offer virtual interviews as an option, especially for those applicants who would otherwise not apply to your program if in-person interviews were mandatory. For example, offer out-of-state medical students the option of either in-person or virtual interviews. Or offer virtual interviews to students living more than 120 miles away. For a residency program in Seattle, the best candidate might be a medical student in Florida but there is little chance that student is going to even apply for residency if it would require flying across the country for an in-person interview. Your future chief resident might be a senior student currently in a medical school 2,500 miles away.

For medical students: When feasible, do in-person interviews. You will learn more about the facilities and the people you will be working with than you can get from the residency program’s website and virtual interviews with two or three faculty members. You can often improve your chances of getting into a residency program because an in-person interview can make you more of a known entity to the program. Interviewing in-person can also indicate your interest in the program since you took the time and expense to travel for the interview. But take advantage of interviewing virtually for those residency programs that you would not have applied to if it required traveling for in-person interviews. This can allow you to interview at more programs that you would have interviewed at had you needed to travel to for in-person interview. It can also save you money for interviewing at residency programs that you would otherwise need to fly to. For more information, see my previous post on making the most of your virtual interview.

Remember who you are competing with

The purpose of a residency program’s resident selection committee is to identify and recruit the best possible medical students. Each residency program competes with all of the other residency programs for those best students. The residency program that offers virtual interviews has a competitive advantage over programs that only offer in-person interviews.

The reason a medical student interviews with multiple residency programs is to get into the residency that he or she is going to learn best in and be happiest in. Each student is competing with all of the other students for the best residency programs. The student that interviews virtually at geographically distant residency programs has an advantage over students who are only willing to do in-person interviews.

April 12, 2024

20% of OB-GYN residents receive their training in states that outright ban abortion. An additional 14% train in states that severely restrict abortion. As a result, one-third of OB-GYN residents face barriers to get adequate training in performing abortion. Unless these residents make special training arrangements, they will be unprepared to safely perform abortions as practicing physicians, even in cases of rape or medical threat to the mother’s life.

ACGME training requirements in OB-GYN

The Accreditation Council for Graduate Medical Education (ACGME) is the organization that sets training requirements for all specialties, including residencies and fellowships. If a residency program fails to meet ACGME requirements, that residency risks losing its accreditation, which can have implication for funding and physician recruitment. Residency programs that are not accredited by the ACGME cannot receive Medicare funding from CMS for Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME). For physicians to obtain board certification, they must train at an ACGME-accredited residency program. Training programs that lose their ACGME accreditation must assist residents to transfer to another residency program and cannot participate in the Match Program. The work that these residents had done must then be performed by attending physicians, at significant cost to the hospital.

The ACGME publishes the requirements for every specialty, including the requirements for OB-GYN residencies. One of these requirements is that OB-GYN residents must be trained to perform abortions; however, residents can opt-out of abortion training if they have religious or moral objections. The converse is not true – residency programs cannot “opt-out” of providing residents training in abortion procedures. In states where abortion is illegal, to be compliant with ACGME requirements, OB-GYN residency programs and their sponsoring hospitals must make arrangements and provide financial support for its residents to get abortion training in another state. The specific wording of these ACGME requirements are:

 

This year, there were 1,557 first-year residency (PGY-1) positions in OB-GYN offered in the 2024 Match. OB-GYN residency lasts for 4 years and thus there are about 6,230 OB-GYN residents in training at any given time in the United States. About 1,260 of these residents are in states where abortion is completely illegal. Unless these residents attest that they have moral or religious objection to abortion, their hospitals must arrange and provide financial support for them to get this training in another state. An additional 848 OB-GYN residents are in states that severely restrict abortion and many of these residents are unable to obtain adequate experience in first and second trimester abortions, as required by the ACGME.

As an example, the University of Texas Southwestern Medical Center in Dallas has the country’s largest OB-GYN residency – 1 out of every 80 OB-GYN physicians in the U.S. did their residency at UT Southwestern. In Texas, abortion is illegal and a physician who performs an abortion is subject to first or second degree felony prosecution. The OB-GYN residency program at UT Southwestern states on its residency website regarding its 4-week family planning rotation: “During this rotation, fourth-year residents have the ability to travel out of state to receive induced abortion training.”

What states ban or restrict abortion?

Since the U.S. Supreme Court overturned Roe v. Wade, it is now up to each state to make its own laws regarding abortion. As a result, these state-specific laws now range from outright bans to restriction based on the number of weeks of gestation to no restrictions on abortion.

In 14 states, abortion is illegal: Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and West Virginia. In an additional 7 states, abortion is severely restricted to less than 6 weeks (Georgia and Alabama), less than 12 weeks (Nebraska and North Carolina), less than 15 weeks (Arizona and Florida), or less than 18 weeks (Utah). In the remaining 29 states, as well as in Puerto Rico and the District of Columbia, abortion is legal with either no gestational limit or a gestational limit sometime in the second trimester of pregnancy.

Implications for the future

In most states, abortion training is a regular component of family planning rotations for OB-GYN residents. Any OB-GYN resident can opt out of this training for religious or moral reasons. OB-GYN residencies in states that prohibit abortion must still provide abortion training as the default option for residents. In the words of the ACGME: “Programs must be structured such that residents may “opt out” rather than needing to “opt in” to this experience.” Nonetheless, there are obstacles that residents in these states face in order to get training in abortion procedures. They have to travel to another state for a month or more of their residency, they have to find and pay for housing in that state, they have to obtain hospital credentialing where they will get the additional training, they have to obtain a state medical license in that state, and they have to be separated from their families for a month or more. There are also burdens on the residency programs. The residency program must still pay the resident’s salary when that resident is out of state getting additional training. Also, when a resident is out of state, that resident has to be taken off of the call schedule and as a result, the rest of the residents must pick up additional nights on-call.

So far, OB-GYN residencies in states that ban or severely restrict abortion have not had their recruitment significantly impacted. In the 2024 residency match, there was no difference in the percent of available PGY-1 resident positions filled in states with an outright ban (99.0%), states with severe restrictions (99.5%), and states with no or minimal restrictions (99.2%). Similarly, there was no difference in the percent of available positions filled by U.S. senior medical (MD) students in states where abortion is illegal (70.5%), states with severe restrictions (73.6%), and states with minimal or no restrictions (71.1%).

But the 527 OB-GYN residents currently training in states that ban or severely restrict abortion face challenges in arranging and paying for out-of-state abortion training during their residency. For many of them, the obstacles attendant to out-of-state training will be too great and they will elect to opt-out of abortion training. As a result, in the future, it may be difficult for them to get jobs in states where abortion is legal. If they do not get training in abortion procedures and post-procedure patient management, then they cannot get hospital privileges to do abortions. This means that even if a woman has a life-threatening complication of her pregnancy, an obstetrician without hospital privileges for abortion procedures must find someone else to perform a life-saving procedure. In states where abortion is legal, given two otherwise equally qualified applicants, the obstetrician applying for a job who is able to perform an abortion will have an advantage over the obstetrician who is not trained in abortion.

Obstetric residents who are not trained in abortion can always get a job in a state where abortion is illegal. However, even in these states, there is usually a provision allowing an obstetrician to perform an abortion if the mother’s life is imminently threatened. An abortion in these women is generally much more complicated and much higher risk than an abortion in an otherwise healthy woman. But if none of the obstetricians in town were trained in performing abortions and in the management of abortion complications, there will not be anyone who can safely do an abortion in a women dying from a complication of pregnancy. You can’t learn how to do any medical or surgical procedure competently by just watching a YouTube video five minutes before you perform your first one. Competently performing an abortion in a high-risk patient is no different.

There are also legal uncertainties in the future for OB-GYN residency programs in states that are dominated by politicians with extreme social conservative stances. For example, will these states withdraw state government funding from hospitals that send their trainees out of state for abortion training? Will they require state-supported hospitals to publicize the names of OB-GYN residents who do out-of-state family planning rotations that include abortion training? Will they revoke the state medical licenses of OB-GYN residents who participate in abortion procedures in other states?

Idaho has one of the most restrictive abortion laws in the country. Since that law went into effect, 22% of its total obstetricians and 55% of its high-risk obstetricians left the state. Idaho is one of six states without an OB-GYN residency program so Idaho’s abortion law has not affected residency training. But medical students are not stupid – if they see that obstetricians are leaving states that ban abortion, they will be a lot less likely to rank OB-GYN residency programs in those states very high on their match rank list.

What can we do now?

It is in our country’s best interest to have our obstetricians trained in the safe performance of abortions and the management of complications of abortions. Otherwise, where will the 12-year-old pregnant rape victim go? Or the woman with an anencephalic fetus? Or the woman with a 15-week pregnancy needing to start chemotherapy for newly diagnosed acute leukemia? Fortunately, there are some specific tactics we can take today.

1. Create training opportunities in OB-GYN residencies in states where abortion is legal. As a general rule, residency training programs do not like to accept visiting residents for a 1 or 2 month rotation. There is a lot of paperwork, there is uncertainty about the skill and ability of visiting residents, and the visiting residents can encroach on the training opportunities of the regular residents. Residency programs and hospitals need to create formal pathways for these OB-GYN residents and take down barriers for these guest residents coming from states where abortion is illegal or severely restricted.
2. Hospitals need to have expedited pathways for credentialing “visiting” OB-GYN residents and should assist them in obtaining state medical licenses for the state that they will be doing their additional training. This could include partnering with residency programs in states with abortion bans in order to streamline the credentialing and licensure process.
3. Not-for-profit organizations need to create funding to assist OB-GYN residents in states where abortion is illegal or severely restricted in order to obtain additional training. This could create grants to help pay for the cost of travel, housing, childcare, medical licensure, etc. Most residents owe money on educational loans with the average amount of those loans about $200,000. Without such grants, many debt-burdened residents simply cannot afford to travel out of state to get abortion training.
4. Medical schools should advise students applying to OB-GYN residencies about the implications of attending residencies in states that ban abortion. This includes how training in these states could potentially affect job prospects in other states where abortion is legal.
5. OB-GYN residency programs in states where abortion is legal can promote to applicants the advantages of training in their program versus programs where abortion is banned. This is a particularly good tactic when the applicants are on-site for their residency interviews and can give the residency program a competitive advantage over residency programs in states where abortion is illegal.
6. OB-GYN residency programs should offer virtual interviews, especially for students applying from out-of-state medical schools. It could be cost-prohibitive for a medical student in Texas to fly to Ohio to interview for an OB-GYN residency position. But by allowing that student to interview virtually from Texas, the OB-GYN residency program in Ohio can open itself up to a larger pool of applicants and potentially end up with a higher quality group of students matching to the residency program. OB-GYN residency programs in states where abortion is legal should now be able to recruit the best student applicants from medical schools in states where abortion is illegal.
7. Hospitals in all states need to review credentialing procedures for obstetricians applying for hospital privileges to perform abortion, even if abortion is only permitted when a pregnant woman’s life is in immediate jeopardy. With one-third of OB-GYN residents training in states where abortion is banned or severely restricted, is is less certain than ever before that an obstetrician who did residency in those states can competently perform an abortion or manage complications of an abortion. This may require hospital credentials committees to remove abortion procedures from the “core privileges” list for OB-GYN and moving them to the “optional privileges” list. Documentation of training should be required.

It’s a new era in OB-GYN

One of the most important (and most frequently forgotten) rules of law-making is that there is always unintended consequences. For example, let’s say that the anti-necktie lobby group got the state legislatures in 21 states to pass a law making it illegal for men to wear a necktie except for Leap Year Day. That would mean that a man could only wear a necktie on one day every 4 years in those states. Eventually, no man in those states is going to remember how to competently tie a necktie and no boys are ever going to learn how to tie a necktie. Men in the 29 states where neckties are legal would have a competitive advantage when it comes to dressing in formalwear. The same thing happens in states with abortion bans – it will not be too long until no one in those states knows how to competently perform an abortion even in the event of rape or the mother’s life being in danger. OB-GYN residency programs in the states (plus Puerto Rico and the District of Columbia) where abortion is legal now have the opportunity to take a competitive advantage in recruitment.

April 8, 2024