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
