10 things medical schools wont tell you

By Jonnelle Marte
Published: Oct 12, 2012 3:33 p.m. ET

How a spoonful of bullying, plus a heaping pile of debt, helps

turn students into doctors
1. Bullying, teaching. Same difference.
By the time most medical school students are assisting in
hospitals shadowing the doctors they aspire to someday
become many are well-accustomed to being pushed
around, yelled at, or called derogatory names.Such incidents
arent new, but with the med student population only growing
(admissions are up 17% since 2002, with schools working to
address a projected shortage of 90,000 doctors by 2020),
cracking down on the problem has becoming a matter of
increasing urgency. Especially in cases of more severe
abuse: A survey conducted this year by the Association of
CandyBox Images / Shutterstock.com
American Medical Colleges, or AAMC, 33% of students said
they were publicly humiliated at least once during medical school, 15% said they were the object of sexist remarks
and 9% said they were required to run errands for doctors.
And a study released this year by the David Geffen School of Medicine at UCLA found that despite several efforts
by the school to hold bullying awareness workshops for third-year students (who bear the brunt of the mistreatment,
because thats when they begin working in hospitals with medical residents and doctors) and to warn residents and
teachers about the consequences of such actions, the abuse has persisted, with more than half of students
surveyed between 1996 and 2008 reporting some form of mistreatment. Part of the problem, says Joyce Fried,
assistant dean at the school of medicine, is that even though the school takes steps, such as waiting until after
grades are awarded before launching investigations, to prevent retaliation toward students who come forward,
many are still afraid to do so.

What to look for in a primary-care doctor

(2:41)
What should you look for in picking a primary-care doctor? The industry expects some movement among patients
and doctors due to full implementation of the federal health overhaul. Anna Mathews has details on Lunch Break.
Photo: Getty Images.
For its part, the AAMC is trying to keep an eye out for abuse: When students finally graduate from medical school,
the AAMC typically sends them a questionnaire, which it recently updated to ask more specific questions about
bullying. Additionally, president Darrell Kirch posted a letter to the AAMC website in September expressing concern
that exposure to bullying could negatively impact a doctors future interactions with patients.
Student advocates say they also worry that such treatment often squelches a students desire to enter the field or
worse yet instills a sense of fear among young doctors that could prevent them from challenging colleagues
when errors are made or from trying new approaches to improve care. Theyre overworked and treated unkindly by
people who are supposed to be teaching them, says Diane Pinakiewicz, president of the National Patient Safety
Foundation, adding that those doctors often go on to mistreat other students when they begin to teach. Were
trying to break the cycle.
2. We just added teamwork to our cutting-edge curriculum...

Before they become doctors, medical school graduates take an oath to do no harm to their patients. But many
critics say the approach medical schools have been taking to reduce medical errors focusing only on the science
may be all wrong. Gaining ground is the school of thought that errors can be prevented by holding all health care
providers including nurse practitioners, physician assistants and anesthesiologists accountable for a groups
mistakes and encouraging them to speak up when something seems amiss. Mistakes can fall through the cracks if
its on the doctor or surgeon to catch all medical errors or if a patients concerns are ignored, says Pinakiewicz. That
means teaching medical students nonmedical skills, like listening, transparency and cooperation.
Top 5 highest-paid college majors

(3:03)
Engineering grads of 2013 earn far higher salaries on average than the typical new college graduate. Lauren Weber
reports. Photo: Getty Images.
Many doctors advocating for this approach can recall a time they were about to give a patient the wrong
prescription or even operate on the wrong body part until a colleague often someone who worked under them
spoke up. At Johns Hopkins University, students are now doing mock briefings in addition to the traditional mock
surgeries, so they can learn all participants names and roles, says Marty Makary, a surgeon at Johns Hopkins
Hospital and author of Unaccountable: What Hospitals Wont Tell You and How Transparency Can Revolutionize
Health Care. The nontechnical or behavioral skills are just as important as the technical skills, says Makary.
3. ... so be prepared to share the spotlight.

Improvements in medical care have made it possible to live longer, but experts say that also means people need
health care for a longer period of time and that conditions are getting more complex. As baby boomers age,
doctors will be faced with more patients who need treatment for multiple conditions diabetes, heart disease,
hypertension and kidney failure, sometimes all at once and theyre going to need to collaborate with nurses,
assistants and other health providers, says Atul Grover, chief public policy officer for the AAMC. There is some
uncertainty about what the role of the physician is going to be versus other members of the team, says Grover.
More doctors steer clear of Medicare

(3:54)
Fewer American doctors are treating patients enrolled in the Medicare health program for seniors, reflecting
frustration with its payment rates and pushback against mounting rules, according to health experts. Stefanie
Ilgenfritz reports. Photo: Ben Sklar for The Wall Street Journal.
Increased roles are being given to nurse practitioners and physician assistants as hospitals look for more costeffective ways to treat chronic conditions, according to a study of safety net hospitals, which serve underinsured
populations, by the Urban Institute published in August. And the approach is getting federal support: In July, the
Department of Health and Human Services announced it was awarding about $200 million to five hospitals, to help
train a greater number of advanced practice registered nurses. Collaboration is also being encouraged by the
medical home model for providing care, a system where primary doctors coordinate hospitals, clinics and other
care providers, which is being promoted as a way to improve care and cut costs under the Affordable Care Act.
Even patients are taking on a more active role in their care, with some people reviewing their doctors notes,
sometimes pointing out errors in their records. For doctors, and aspiring physicians, the increased collaboration
could mean a reduction in how much doctors are paid versus other members of the team, says Grover.
4. Youre not getting in here without some people skills.

Stellar grades and a top-notch MCAT score are no longer a guaranteed ticket to medical school prospective
students now often have to pass a personality test if they want to move to the next level. As more insiders come to
agree that better communication is the key to preventing medical mistakes, schools are rolling out more thorough
ways to screen for associated traits, like professionalism and the aforementioned listening skills and affinity for
teamwork. And those test results may say more about a students chances of success than the MCAT, says Henry
Sondheimer, a retired pediatrician and director of the holistic review project at the AAMC, which is encouraging
schools to better incorporate such factors into admissions.
Women over 30? time to talk baby, doctors say

(3:41)
Doctors increasingly have a message for women in their 30s: Have a baby before you get older. "Your Health"
columnist Sumathi Reddy and NYU Fertility Center co-founder and director of reproductive surgery Dr. Nicole
Noyes join Lunch Break to discuss. Photo: Getty Images.
Indeed, MCAT scores only seem to be a good indicator of future potential when they are far below average:
Students had similar chances of graduating in four years if they scored between a 24 and a 45 (the highest
possible) on the MCAT, according to an AAMC study of students who entered medical school from 2004 to 2006.
Those chances only dropped off significantly for those who scored in the low 20s and teens. Thats why schools are
looking less at the score and more at the whole person, admissions experts say. The change is away from picking
medical students to picking future physicians,says Sondheimer.
About 20 schools in the U.S. are now requiring students to go through as many as 10 mini interviews with faculty
members instead of the traditional one or two where they are asked about how they would handle certain
scenarios or how they feel about various aspects of care, says Sondheimer. The results are analyzed at times by a
trained psychologist, he says. The process has become more popular over the past three years, and some schools
in the U.S. and Canada are also testing out a virtual version of the exam. Some nonmedical employers are also
using personality tests to help weed out applicants who may not be a good fit for the job, a move experts say may
also help job applicants and med students figure out early if theyre pursuing the right career.
5. Undergraduate transferring may be used against you.

An AAMC study of college transcripts for 31,000 applicants to U.S. medical schools in 2011 found that students who
attended multiple undergraduate schools were less likely to get accepted into medical schools than those who only
attended one college. The acceptance rate was 52.3% for those who went to one school, versus 48.3% for those
who went to two schools and just 38.6% for those who went to five or more schools. While several factors could be
to blame (such as poor guidance from faculty or complicating life events), those applicants who went to multiple
schools also had slightly lower MCAT scores than those who only attended one college.
When patients lie to the doctor

(3:12)
Patient lies-from half truths and deceptions to bold, blatant lies-are surprisingly common in today's hurried medical
practices, doctors say. WSJ's Sumathi Reddy joins Lunch Break with a look at why we lie and what tips off doctors.
Photo: Getty.
The report notes that the trend might inordinately impact low-income students and minorities like African Americans
or Latinos, who are more likely to attend multiple institutions. Its also something medical schools may have to
address at a time when more undergraduate students are attending community colleges and transferring schools in
an effort to lower tuition costs, says Sondheimer, of the AAMC. More than 60% of applicants in the study, for
instance, went to two or more schools. That means schools are likely to see more applicants that went to several
schools in the coming years, he says, adding that the findings arent meant to be a guide or a deterrent for
medical school applicants. Other factors such as extracurricular activities, community service experience, and
letters of recommendation, could have a greater impact on their chances of getting accepted than the type of school
they attended, he says.
6. Getting into med school was tough? Try getting a residency.

Just as monumental as graduation day is Match Day, when medical school students get sealed envelopes that tell
them what city and hospital theyll be going to for training. But advocates say the number of grads could severely
outnumber the amount of residency positions by 2015 or sooner if hospitals dont substantially expand the
number of residency positions they offer. While medical school enrollment is on track to grow by 30% by 2016 from
2002 levels, the number of residency training positions have only grown by 8% since 2002, according to the AAMC.
Even as theres an impending doctor shortage, Were worried were going to have a group of MDs that have
studied but cant practice because they cant find a training spot, says Grover of the AAMC. Part of the problem is
that theres a cap on the amount of Medicare dollars that can go to residency programs that has been in place since
1997, when some health experts predicted that there was going to be an oversupply of physicians in the U.S.
Health insurer to pay doctors more

(3:33)
The nation's second-largest health insurer, WellPoint Inc., which insures some 34 million Americans, will offer
primary-care doctors a fee increase with the possibility of additional payments, Christopher Weaver reports on
Markets Hub. (Photo: AP/Michael Conroy)
About 20% of the $13 billion spent annually on training 110,000 young doctors is provided by Medicare, down from
roughly 30% a decade ago, estimates Grover. If Congress doesnt act to allow Medicare to fund a larger number of
positions, hospitals may need to find additional revenue to fill the gap, and some may need to reduce the number of
positions they offer, he adds. At a time when the federal government is cutting Medicare spending and some
hospitals are already seeing their budgets squeezed, finding additional revenue for new training positions will be
tough, says Grover. Its even possible that graduates might soon also be asked to pay for the training an option
that some insiders say would place an unreasonable burden on already debt-laden doctors instead of the current

model where they are paid while they work at the hospitals, says John Norcini, president of the Foundation for
Advancement of International Medical Education and Research: Theres a whole series of possibilities. Theres
still hope though for the Medicare option: One bipartisan bill recently introduced by Reps. Aaron Schock (R-Ill.) and
Allyson Schwartz (D-Pa.) calls for increasing the number of Medicare-backed training slots by 15,000 over the next
5 years, which could train up to 4,000 new doctors. But no action on the bill is expected until after the election.
7. Offshoring is not just for factories anymore

Despite the increase in graduating class sizes at U.S. medical schools in the past decade, competition for U.S.
schools remains fierce, forcing those who dont make the cut to consider studying abroad, where flexible starting
dates might appeal to aspiring doctors who dont want to wait a year for another chance at a U.S. school. Of the
43,919 people who applied to U.S. medical schools last year, only about 40% landed a coveted spot in the starting
class of 2011-12.
Chinese applicants flooding U.S. graduate schools

(5:23)
Dow Jones Newswires reporter Melissa Korn checks in on Mean Street to highlight the growing number of Chinese
students applying for enrollment at U.S. graduate schools.
U.S. students attending foreign schools often face higher costs, unfamiliar lifestyles and more difficulty landing
residencies in the U.S., but for many, its their best shot at becoming a doctor. After Thomas Gabro wasnt granted
interviews for any of the 12 U.S. schools he applied to last fall, he decided to try for the Ross University School of
Medicine in Dominica, where he is now a second year med student. Tuition there averages $53,000 a year, about
20% more than the average tuition at a private medical school in the U.S. But despite the higher costs, a spotty
phone connection, and being apart from his family in Tampa, Gabro, 22, says he made the right choice. It was my
last option, says Gabro, who estimates he will graduate with $225,000 in debt. I had to do what I had to do.
Experts say international med students will play a key role in filling a potential doctor shortage in the U.S. in the
coming decades as baby boomers age and overall health care needs increase. But students who want to go abroad
may face challenges selecting the right school and getting the training they need. A study of medical schools by the
Foundation for Advancement of International Medical Education and Research found that the performance of
doctors educated in the Caribbean over the past decade varied widely by country. However, graduates of those
schools in Dominica and Grenada whose students often apply for medical licenses in the U.S. showed relatively
consistent performance over the years.
Post-graduate training presents another obstacle: U.S. citizens who attend international schools have a much lower
chance of landing a residency in the U.S. 49%, compared with 95% for seniors at U.S. medical schools,
according to the National Resident Matching Program, a not-for-profit company that helps match students with
residency programs. And completing a residency program abroad isnt a viable option for young doctors who want
to practice at home, since graduates typically need to train in the U.S. if they want to get a medical license here,
says John Norcini, president of the Educational Commission for Foreign Medical Graduates. But U.S. students
shouldnt write off international schools: A 2010 report from the Foundation for Advancement of International
Medical Education and Research found that patients treated by doctors who studied abroad had similar mortality
rates to those who were treated by doctors who studied in the U.S.
8. but your foreign colleagues may put your skills to shame.
Cancer: The patient survives, but now what?

(4:54)

A new push for cancer "rehab" is helping patients avoid long-term physical disability and complications after
treatment ends. WSJ's Laura Landro and Julie Silver, Harvard Medical School assistant professor, discuss on
Lunch Break. Photo: Getty Images.
While that same study by the Foundation for Advancement of International Medical Education and Research found
that doctors trained in the U.S. had comparable results overall to doctors trained abroad, it did show a significant
difference in outcomes between U.S. citizens and non-U.S. citizens who studied internationally. The study looked at
congestive heart failure cases and acute myocardial infractions at 184 hospitals from 2003 to 2006 and found that
the mortality rate was lowest for patients of non-U.S.-citizen international graduates and highest for patients of U.S.citizen international graduates.
U.S.-citizen international graduates also had lower scores on cognitive portions of the licensing exam, lower ratings
from training program directors and lower rates of specialty board certification, according to the research. Its not
clear, however, what is behind the disparity. More research is needed to determine if the difference is due to the
quality of the international schools being chosen by U.S. citizens or if its a sign of the skills of the doctors
themselves, the report notes. Potential students ultimately need additional research on what works in medical
education and the characteristics of international schools, says Norcini. It might also mean a tougher acceptance
process down the line for medical schools and residency programs, the study says.
9. Indebtedness isnt an illness among doctors its a plague.

The vast majority of medical students including 87% of the class of 2011 graduate with some amount of
education debt, according to the AAMC. And the share of graduates who have at least $200,000 in undergraduate
and medical school debt was 33% in 2011, up from 27% in 2008. By comparison, the average student-loan debt
load held by all consumers under 30 is roughly $21,000, according to the Federal Reserve Bank of New York.
Critics blame rising tuition costs: Private medical schools have increased tuition by 11% over the same time period.
Pet medical care skyrockets

(3:26)
The cost of medical care for pets is skyrocketing. The proliferation of advanced medical tests and long-term
treatments have made pet ownership a significant financial commitment. Wendy Bounds has details on The News
Hub.
That burden weighs on doctors throughout their careers, potentially impacting their ability to buy a home or take out
other needed loans. But more importantly, it can influence which specialty they choose, says Todd Balsley,
executive vice president at GL Advisor, a financial advisory firm that specializes in working with young professionals
with graduate school debt. The median starting salary for primary care physicians was $168,000 in 2011, while pay
for neurosurgeons, among the highest-paid of specialties, was three times that, according to the Medical Group
Management Association. Jessica Clemons, a second year medical student at Weill Cornell Medical College, wants
to practice primary medicine for underserved communities when she becomes a doctor, but worries the $120,000 in
debt she will likely graduate with may push her into a more lucrative specialty. [Primary care] is where my heart is,
says Clemons, 28. But in comparison to the amount of debt Im going to have, its going to be very difficult.
Some insiders say such salary gaps are contributing to a shortage of primary care physicians. But thats not the
only thing dissuading students from primary care: Doctors could also be turned away by the fact that primary care
doctors tend to work longer hours, says Todd Evenson, director of data solutions for the MGMA.
There are a few options though for debt-averse hopefuls. Medical students who choose to be primary care doctors

are getting some help from the Affordable Care Act, which created a loan repayment assistance program for
graduates who commit to working in underserved communities for at least three years. And young doctors
across specialties can make their payments more manageable by enrolling in federal income-based repayment
programs offered by the Department of Education that cap loan repayments based on how much the graduate is
making and that forgive debts after 25 years of qualified payments, says Balsley. Graduates would be taxed,
however, on the forgiven amount and could end up paying more interest under the program if they extend the life of
their loan, Balsley notes.
10. Medicine isnt a prescription for riches.

As experts try to find more cost-efficient ways of delivering medicine, the pay structure for doctors is being
reevaluated and pay could be cut. Under the Affordable Care Act, reimbursement rates for Medicare Advantage
plans, a type of Medicare plan offered by private insurers, are being reduced to the lower level paid by traditional
Medicare. And some private insurance companies may follow suit as a way to cope with higher health care costs,
says Phillip Miller, vice president of communications for Merritt Hawkins, a physician consulting firm.
Medical manikins simulate real-life emergencies

(2:50)
They speak, breathe and even bleed. High-tech manikins are the latest trend in medical education that offer
students and professionals alike an opportunity to practice under pressure. WSJ's Christina Tsuei reports.
Alternative pay structures being considered could also lower compensation for physicians who dont meet certain
thresholds for performance. Someinsurance companies are rolling out pilot programs where doctors and other
providers are compensated based on healthy outcomes, instead of quantity of services an aspect introduced by
the health care reform legislation. And one model being considered by the Center for Medicare & Medicaid Services
would bundle payments for multiple services a patient might receive for care, instead of filing several individual
claims by the hospital, the anesthesiologist, and other providers.
Some experts say payment cuts to health care providers could be more severe and jobs could be lost if
Congress fails to prevent the automatic spending cuts scheduled to take place next year that would cut Medicare
funding by 2% over the next nine years. As many as 496,000 jobs at hospitals, doctors offices, medical labs and
other sectors beyond health care could be lost in 2013 if the mandatory cuts to payments are allowed, according to
a study done last summer by health care and higher education consulting firm Tripp Umbach. But health care needs
arent expected to slow if the cuts happen, meaning the doctors who are left might have to care for a growing
number of patients with less help from supporting staff, says Paul Umbach, president and chief executive officer of
Tripp Umbach. It deters the young people wanting to be physicians, he says.
However, that worst case scenario could be avoided if Congress acts before the end of the year. And while
physicians are facing uncertainty over how theyll get paid, doctors salaries overall are unlikely to shrink
dramatically, says Todd Evenson, director of data solutions for the MGMA. Nonetheless, many physicians, tired of
struggling to keep their private practices afloat at a time when some insurers are cutting reimbursement rates, are
going to work for hospitals. The model is especially appealing to young doctors: 62% of doctors under the age of 40
are employed by a hospital or other entity, according to a 2012 survey of physicians by Merritt Hawkins for The
Physicians Foundation. See also: 10 things bars wont tell you

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