Chapter 5
PRE-MED: VULNERABILITY AND TRAUMA
Scenario
Mr. Howard surveyed his class of 20 high school seniors who were sitting at their desks attentively listening to him. They all looked so young. All were serious and had their laptops open, either to take notes from the upcoming talk or to do something more interesting online. They had asked him to set up this talk, and he had been happy to oblige.
“As we discussed last week, it is a great pleasure to have Luis Garcia here. Luis was a senior here just over 5 years ago, and next semester he’s going to start medical school. He is living proof that all of you can succeed if you work hard and plan your careers carefully. He is someone who is committed to helping his community, and it is very kind of him to come here and tell you his story. I hope it will give you some ideas for yourselves and the confidence to push yourselves forward to success, just like he has.” He looked around the room. “Before I invite Luis to speak, I want to tell you a brief story about him. I first taught Luis when he was a junior in my biology class. As many of you have done, we had to do some dissection of frogs to examine their anatomy. It was evident that Luis really hated doing that, mainly because he didn’t like the idea of the frogs being sacrificed for his learning. I remember that he looked queasy, and I thought he was going to be sick, but he managed to get over that and did a great dissection. When I spoke to him after class about how he felt, he told me he’d been thinking of trying to become a veterinarian or a doctor, and he was worried about the reaction he’d had to the frog. We had several long chats about this issue, and eventually Luis started dropping by to speak to me about other academic ideas he had. This led to him deciding to study biology at college, with the aim of going into one of the health professions. I’m not sure he’ll ever be a surgeon, but I do know that he is a caring and gentle person who will make a great physician and will comfort a great many people, whatever he does.”
Turning to Luis, Mr. Howard laughed, reminiscing. “I don’t know if you remember that class, Luis, but you really did look like you were going to be sick. I’m looking forward to finding out what sort of physician you become. Maybe you could include some of your long-term ambitions in your talk today. I’m fascinated to know how you are thinking now.” He turned back to his class. “Students, please welcome Luis back to his old school, and let’s listen to his advice as to how to get through college and into medical school. Do please take over now, Luis.”
Luis, who had been standing just behind his mentor, moved forward to address the class. “Being back at school in Mr. Howard’s classroom is really like a homecoming for me. Just so all of you know, if you don’t already, Mr. Howard was incredibly helpful to me, and I will always be grateful for everything you did, sir.” He looked across at his longtime academic mentor gratefully and smiled. Mr. Howard looked down, somewhat embarrassed but secretly pleased at the acknowledgment. He certainly was pleased at how well Luis had done so far in his career.
Luis continued. “When Mr. Howard asked me to come and talk to you, he asked if I would tell you my story and about how I managed to get into medical school. He said he really wanted me to tell you what I have learned about the process, and what I will need to do in the future to become a good physician and help my future patients. Of course, I don’t know all of that yet. I haven’t even started medical school, but I’ve been accepted. It’s been really hard to get here, and I’m so glad to be at this point in my life. I spent a lot of time learning about what I can expect. I wanted to know about the life of a physician and how it is changing; what I will likely be faced with in the future; and what sorts of skills and knowledge I will need to develop in order to become a good doctor while at the same time having a full and happy life in general. Mr. Howard told me that you are all studying STEM1 topics, and some of you are aiming to go to a college with a pre-med program so that you can eventually become doctors. It’s great that you are thinking and planning ahead, because that is one of the skills every good doctor needs.”
He looked around the room and could see that he had everyone’s attention; no one seemed to be browsing the web or posting on social media. Just as he was feeling confident that he had the whole class with him, his phone—sitting on the desk beside him—beeped. A tweet with a photo of him addressing the class had been posted. So much for keeping their full attention! he thought. At least one of them was on social media.
Luis decided to ignore Twitter, muted his phone, and focused on the audience. He felt surprisingly confident about giving this talk after all of the public speaking practice he had had recently, and he decided to ask them all to put their phones away and on mute so that they weren’t distracted for the next hour. He had prepared the outline of this talk carefully and had the main points easily available—ironically, on his phone’s note application—in case he became anxious and forgot to talk about some of his experiences. He had thought about how to dress for this occasion so that he could not only connect with the group but also look more professional than he usually did; his usual worn jeans and baseball cap would not suffice. He was wearing light slacks and a collared shirt with his best brown leather shoes. Giving up his attempt to grow a beard, he also had shaved for today, and his reflection in the mirror this morning had looked more mature and manly than usual.
“First, I want to make it clear that I am fine with you asking any questions as we go along. Just put your hand up. Second, I’m going to try to keep this talk a bit mysterious by not telling you which medical school I’m going to attend until the very end. That way, I can talk more about what I learned without biasing you, in case you happen to know the school.” He took a breath.
“Let me start at the beginning of my story. I was about 10 years old when I first thought of trying to become a doctor, and I got serious about it when I entered high school. Let me ask you this: How old were you when you started to think seriously about medicine as a career? Who was like me and thought about this before middle school?”
About half the hands in the room went up. Luis chose a redheaded student in the second row and asked her to tell the class how her story began. “My name is Ann,” she said. “And I can remember dressing up as a doctor when I was about 5 or 6 years old. We had a lot of ill health in my home; Dad was constantly sick and in bed, and I was the eldest of four children, so Mom really depended on me to help her. He died of chronic liver disease just before I started high school. Most of my life up to that time had been focused on him. I remember telling him when I was about 8 that I would become a doctor so I could cure him, because he had told me several times that there was no cure for his illness. I haven’t ever really thought of doing anything else and have already done several volunteer jobs during school holidays, such as assisting at local clinics, where I get to see doctors working. My family doctor knows what I want to do and has told me that if I can get into pre-med at college, he will let me shadow him. I’m really looking forward to that.”
“Thanks Ann,” Luis responded. “It sounds like you’ve certainly made up your mind. What do your mom and others in your family think of your plan?”
“They mostly think it’s a good idea, although my grandma is concerned about the amount of work I do to make sure my grades are good, never mind the time I spend going to clinics after school. She keeps saying I should have more fun and do some sports or art. But I think that if I want to succeed in something like being a doctor, I will always have to work hard. If that means sacrificing some of my other activities for a while, then I think that would be worth it. After all, how can I ever become a liver doctor, and help cure the disease that killed my dad, if I don’t work hard?”
Luis looked intently at Ann and then addressed the whole class. “I wonder what everyone else thinks of what Ann is doing? She certainly sounds very determined. Are you doing the same? How hard do you think you have to work to get into medical school? Should you give up your outside interests?”
A boy wearing scruffy clothes and long, unkempt hair who was sitting in the back row responded almost immediately. “We all know Ann. She answers every question first, just like she did with you. She always wants to get the best grades and is super focused on work. It’s a disaster, and she thinks she has failed completely, if she doesn’t get an A+. We all know about her dad and his illness, and the other problems she had at home as a child, because she talks about them a lot. Personally, I think she makes too much of them; we have all told her lots of times that if she really does want to go to medical school, she should try to do other things apart from work. Who wants to see a doctor who has no other interests in life, who doesn’t go to concerts or hang out with friends at least a few days a week? I certainly wouldn’t.”
“That’s just because I always do better than you in class, Simon. You’re jealous, as usual. In case you don’t know, I do listen to music. A lot. At home,” Ann responded defensively.
“Now, now guys,” Luis intervened. “Let’s not get too judgmental. But that’s actually a really important point, Simon, and something I learned when I started finding out about how to get admitted to medical school. Ann, I know you’re trying to do the right thing, but I also have sympathy for Simon’s view in this case, and I think he means to give you good advice. One of the areas admissions committees look at is a person’s life experiences and breadth of knowledge, and they much prefer applicants who have broad backgrounds and who have succeeded in areas outside of medicine. They want to see if students have really done things and participated in projects, possibly showing leadership qualities rather than observing much of the time, although doing some shadowing is always good because it makes you sure of your career decision. I certainly did that early on.”
Luis decided he was being drawn a bit off track by this conversation and moved to bring his talk back to his original plan.
“We’ve talked about three key things so far about medical school admission. First, many students make up their minds to go into health care very early, perhaps sometimes too early. Second, quite a few kids go into medicine partly because of their life experiences of illness as children or adolescents, rather like Ann. Third, although hard work and a strong focus on getting good grades is essential, it’s best if this can be combined with other interests or experiences outside of the health care world, especially through leadership roles in almost any area. My big message to you all is that it is possible to overcome adversity and do well in life, and becoming a doctor is one way of doing this. The trick is learning to both work hard and play hard, and to enjoy both.”
Luis relaxed and sat on the desk at the front of the class, facing the students, with his legs dangling free in front and his torso and head slightly above theirs, a position that allowed him to dominate the group. “Now, let me tell you my personal story, and you’ll see how all of those issues have been important to me. I was like Ann in many respects. I came from a poor family, and my father died when I was very young. I had a really difficult childhood; my mother didn’t cope well with my brother and me, so we really had to bring ourselves up, often feeling neglected and very alone. By the time I was about 8 years old, I had started taking on the role of the male head of the household. I was responsible for my brother and for helping my mom, whom I now believe must have been depressed for years. She drowned her sorrows drinking cheap wine, or vodka in a ‘water bottle’ that never left her side, and eating comfort food. I remember scavenging from the dumpsters behind the supermarket to get food that had been thrown out. We had to go on public assistance for several years, and we lived in an awful area of the city, where gangs and violence surrounded us. Despite this, our situation forced me to work hard at school, and I think that’s what saved me. I felt responsible for my younger brother, so I did the best I could. Like Ann, I was the eldest in the family, and from an early age I learned the importance of eating right—mainly because my overweight mother with insulin-dependent diabetes didn’t do so. She was always talking to us about the importance of nutrition, but we knew perfectly well that she survived on fast food most of the time, and we were well aware that she was drinking heavily.
“By the time I was a teenager, Mom had remarried, to a man she had met at Alcoholics Anonymous. The whole family became overly focused on food and diets, perhaps as another form of addiction instead of alcohol. I was a bright, young kid, so I started to read a lot about this topic to try to understand why Mom’s diabetes was so badly out of control. I remember doing a school project on diabetes and learning why my mom just kept getting sicker all the time; she was eating all the wrong things. I couldn’t get her to change, but at least I began to understand what was going on with her. I was just a sensitive kid who was trying to do his best to help.”
Luis continued to describe the development of his fascination with biology during high school, and how Mr. Howard had taken a real interest in him and had both mentored and challenged him academically. He talked about how he had become serious about getting into medical school by the time he was a sophomore. At that stage, he was helping run health booths with the local public health department on the weekends and began to understand the connections between basic biological processes and a number of diseases. He learned how to take vitals and simple histories from people attending the booth, and because he continued his volunteering throughout his time at high school, he ended up doing some simple counseling to attendees and giving out relevant literature on obesity, diabetes, and excessive drinking.
Luis tried to move through this section of the talk quickly, because he knew the students were all past this stage and would be more interested in what they were likely to face next. He emphasized that he became a runner because that sport cost no money, unlike football with all its attendant gear; he could literally just sprint out the front door to escape his sometimes-toxic home environment whenever he had time. He described learning that he had been sponsored to go on a school trip to Asia the summer after his senior year, which had given him a real taste for travel and seeing other cultures. He never had learned who the sponsor was.
“What did you do when you went to college? How could you afford it, and how did you pick your courses there?” asked a well-dressed, rather intent Hispanic student.
“The first thing I did was join the pre-med student society. In fact, one of the reasons I went to City University was because they had a strong pre-med program and seemed to have a lot of students succeed in getting into medical or health care graduate programs. But before that, I must emphasize that I did a lot of planning and researching. Mr. Howard pointed me in the right direction many times. He told me how to find lots of scholarships for people like me. It’s amazing what’s available on the internet, and how all the medical schools have differing academic prerequisites that you have to meet. Later I’ll give you a list of websites I’ve found useful.”
He continued. “You mentioned picking courses. That is crucial, because you don’t want to suddenly find that you need to do physics at the same time as you are taking the MCAT or are about to submit your medical school application in AMCAS. Do you all know those acronyms? If you want to work in health care, you are going to have to love acronyms! The Medical College Admissions Test, or MCAT, is the exam all intending medical students have to take, and the American Medical College Admission Service, or AMCAS, is the place you apply to for entry. Anyway, getting back to your question, my advice is to make sure you use your college advisors and, at the same time, start to identify possible medical schools as early as you can and check out their requirements for admission.”
Another student put up her hand. “I know that all medical schools are different, so what sorts of things did you look for when you started researching them to see where might be best for you? After all, we’re all different individuals and have different needs.”
“I’m really pleased you asked that question,” Luis replied. “I think you all should be trying to match your own needs with your ideal school. Your question leads to what I think was the most important reason behind my decision regarding school choice, and it all happened during my final year of college, when I went to a special lecture arranged by the college pre-med society.”
Luis paused while he collected his thoughts and wondered how much personal exposure would be appropriate.
“Let me give you a bit of background. For the first time in my life, about 18 months ago, I was having a really hard time. My grades had slipped, and I felt miserable for several months for no obvious reason. I was seriously thinking of abandoning the idea of medicine and doing something both easier and less stressful. I doubted that I could get into medical school and just wasn’t sure which schools might suit me best, despite doing a lot of research. A whole lot of things happened at once. My girlfriend of 2 years left me, saying I was no fun anymore because I worked too much. She was angry with me and made a whole lot of nasty posts on Facebook that were very embarrassing and have haunted me since. I’ve heard all sorts of stories about the importance of a good online media profile for medical school admission. Anyway, she did finally agree to delete them before my school interviews, much to my relief, because having done the interviews, I now know it‘s important to have a good online profile. You all need to be aware of that and not allow yourselves to be photographed doing things that might embarrass you later.
“Anyway, at the same time all this was going on, I pulled a knee ligament during a pickup game of basketball and had to stop running for several months. Then my mom, who had already gone blind from her poorly controlled diabetes, had a heart attack and died suddenly at home. All of these things meant I wasn’t keeping up with my studies and was just feeling totally beaten.” Luis looked around the room and could see that the students had not been expecting this section of the story. They were completely quiet. A pin dropping would have been like a drumroll in the silent room.
He went on. “Imagine my reaction when I found out that the topic of the keynote lecture for our pre-med society annual meeting was ‘physician well-being.’ I was certainly pretty down and upset, and at times quite depressed, even tearful. I was doubting my career choice, but suddenly, here is this lecture topic that really piqued my interest. Possibly a good omen.”
Luis stood up and walked around the front of the class, stretching his legs and taking his time. He wanted to give the students a message that, to him, was of great importance.
“So, I went to the lecture. Rather reluctantly, to be honest, but hopeful and eager to learn something that I might relate to. It turned out to be a life-changing event for me. My eyes were completely opened to the possibilities of medicine. I started to feel positive about my career choice again, although Mr. Howard is right, I cannot imagine being a surgeon. I’m sure most of you have had special moments happen that have been very influential for you. This was mine.”
Luis looked across at Mr. Howard, the only person in the room who knew what was coming. He sought reassurance, which he received via an encouraging smile and a slight nod of the head. He continued.
“There’s one thing I didn’t mention earlier, when I talked about my family background and why I was so interested in going into medicine. I told you about my mom’s diabetes, and how I had such a hard childhood. How she was not a good patient, eating the wrong foods and not exercising. One of the reasons I had to help her so much was because my dad had died when I was only 2 years old, and I don’t think my mom ever recovered from that. I found out years ago that my dad had been a doctor, although Mom always refused to talk about him. One of my reasons for being so keen on a medical career was to follow in his footsteps.” He paused. “What I had no idea about, until last year just before my mom died when she finally decided to tell me about him, was that he had had alcoholism and had eventually committed suicide. She had kept this a secret from the whole family all these years because of the stigma surrounding his death. A medical friend of his wrote ‘cardiac arrest’ on his death certificate, and everything was hushed up. The only reason Mom told me about this before she died was because she was afraid that if I went into medicine, I would do the same.”
Luis stopped talking and momentarily looked out of the window. White puffs of clouds skated across a bright blue sky. The listening students were tense, surprised, and fascinated.
“She’d kept the suicide note he had written all those years ago and gave it to me a week before she died. It seems that he took a massive overdose of narcotic painkillers with whiskey and never woke up. His letter was so sad. He seems to have been overworking as the only family medicine doctor in the country town where we lived; he was always on call and always available. He described how he blamed himself for the death of a child because he believed he’d missed some early signs of meningitis, although my mom said that was not true. After that, he gradually lost confidence in his ability. In his letter to Mom, he said he felt hopeless, guilty, alone, and ashamed and didn’t want any help, nor did he deserve it. He wrote that he was afraid that his ‘mistake’ would always be remembered by the community; that he would be unable to bear the public shame and blame; and that everyone would be better off without him. Mom said she had been trying to persuade him to see a colleague for help, but he kept refusing to the end, saying that all doctors were trained to be tough and to look after themselves.”
Somewhat surprised by how painful this public discussion was, Luis took a moment of reflection, looking around at the students and meeting Mr. Howard’s warm and friendly eyes. He held his emotions back with difficulty, although he could feel his tears forming, and pulled out a tissue to wipe his nose and eyes.
“You can imagine how painful it was to have suddenly discovered all this about my dad, while already having uncertainties about my own future. It was hardly surprising I was having doubts about my career choice. Going to that talk at that time was the best thing I could have ever done, because it made me think of medicine in a different light. The speaker acknowledged that even doctors were humans and had problems, but she was really hopeful and optimistic about the ways they could be helped. I’d been thinking that with all my family problems I would not be able to manage medical school, but I suddenly now saw that this was possible and that many schools had extra help available for students who were having difficulties. Why, the lecturer even talked about how helping doctors was becoming a new potential career path for some physicians—a bit like being a car mechanic preventing cars from deteriorating, if you see what I mean.”
A hand went up, rather hesitantly, belonging to a young black student. “I don’t quite get it,” he said. “How can that be a career path? Was she talking about her own experiences? And why would you want to work in that area after what happened to your dad?”
“You’re right to ask those questions,” Luis responded. “I must say that when I went to the talk, I was expecting that the speaker, who was a family physician like my dad, would be talking about her own experiences or something like that. But I was completely wrong. She did talk a lot about the stresses of practicing medicine and how, over the years, she has changed her practice. She now specializes in seeing physicians and has many doctors as patients in her half-time clinical practice. She said she has much more control over how she practices, and her patients are all prepared to pay for her to spend more time with them than used to be the case when she had a more general practice. She does all the regular medical checkups they need, and she works closely with a small network of psychiatrists, addiction specialists, and internal medicine experts to whom she can refer patients if necessary. She made the point that by doing that, she was not only providing better care for her patients but also practicing what she called ‘self-care’ because she found her new style of practice much less personally stressful.”
Another student chimed in. “My name is Claire, and I’m planning on pre-med next year. I think I understand where you’re going with this, but it’s just so odd to think that doctors need help. They always seem to be the ones we go to for help. We just assume that doctors take care of themselves and do what they tell everyone else to do. I think of doctors as being so committed that they pretty much work all the time because that’s just what they do. It’s their job.”
“Yes,” Luis answered. “We all expect doctors to work hard, but they also need time to refresh, like everyone else. It’s part of being healthy. The basics of good nutrition and work-life balance are critical for doctors. You can’t be effective if you’re worn out and not feeling your best. It actually takes thinking and planning to keep fit and healthy, and doctors must do that for themselves—not just tell everyone else to do it. Some articles now describe how to identify and treat doctors like my dad, and others who have addictions, as well as lots who were burned out, mainly from administrative demands. To me, the most important message is that all doctors need to focus on self-care much more. It made me really think about my dad. My mom swore that my dad was found not to be responsible for the death of that child. She said he’d become depressed and worn out, and the child’s death was the final straw. He worked 12–14 hours a day and made rounds most weekends. He apparently had no outside interests. Doctors didn’t really seek help in those days. Colleagues didn’t intervene. It was just ignored, and that’s what finally did it. He was tired and lost hope along the way.” Luis stopped again. He thought deeply about how best to move on with his talk.
“I said that going to that talk was life changing for me, especially in relation to finding out about my dad. Well, it made me suddenly think that aiming to become a doctor in order to help other doctors, and maybe also other types of health care professionals, would be a really rewarding career. I can’t be sure if that’s what I will end up doing, of course, but at least it’s an interesting option to think about and to explore. It made me think very differently about medical school and led me to do a lot more research on which school to go to.”
Mr. Howard put up his hand. “Luis, you will have to finish in a few minutes. I wonder if you could focus on your research and how it led to you selecting possible medical schools for yourself?”
“Certainly. Thanks, Mr. Howard. Well, it was tricky. When you look at what most medical schools put on the internet for pre-med students, the topic of physician well-being really doesn’t come up much at all. Hardly anything can be found on the subject, even on the AAMC—that’s the Association of American Medical Colleges—website, which is really surprising to me. So, I went to my faculty mentor at City University, but she didn’t really have many ideas. I remembered that Mr. Howard had always said I could come back to see him, so that’s what I did. We spent an hour together searching for education programs on physician health, and I hate to think how much extra time you spent on your own, Mr. Howard, but the list of resources you sent me was great. The breakthrough came when Mr. Howard asked me if I’d followed up with the doctor who’d given the lecture on physician well-being. I felt like a complete fool, because she was the obvious person to approach! So that’s what I did. She was kind enough to see me and was able to give me a whole lot of good inside knowledge about what sort of school to go to and which have the best well-being programs for students and faculty. Surprisingly, she told me no specific training programs have been established yet for doctors who want to treat or help doctors, although they are being developed and might be around by the time I’m through residency.”
“What did she suggest you do then, Luis?” asked Mr. Howard.
“She was really practical and helpful. She said that I should first look for a medical school that has a strong wellness program and a lot of resources to help students, because that is a clear indicator that they see student health as being of great importance. Then she said to look for the ones that also seemed to have similar programs for residents, which again are usually straightforward to find and compare. Next, she suggested I check out the schools’ interests in primary care and public health, and whether they were strong in these areas, and also determine if they had good residency programs in primary care and psychiatry, which she thought would be the most relevant disciplines. Her overall view was that if a medical school covered all of these bases, it would most likely provide me with training opportunities I would value. I did all of that. It’s surprising how few medical schools exist that meet all of those criteria. I was able to search among my top medical schools and pick out the ones that seemed to have the best programs, and those were the schools I listed as my top preferences. Then, when I was lucky enough to be offered four interviews, I made sure that I asked about wellness as much as possible when I visited the schools, to gauge how effective the programs were and what level of commitment they really had to them.”
Another hand went up from a woman in the back row. “Still, it must be hard to try and work out the best school when there really aren’t any training programs in the field you think you want to work in. Did you do anything else?”
“Good point,” said Luis. “I guess I was lucky. Dr. Evansly, the well-being lecturer, was just wonderful with me and was more than willing for me to contact her again and run my ideas past her. Of course, she had her own biases and made it clear that she thought I should apply to her medical school, which was one of the four that I interviewed with. I telephoned her after each interview to process what I’d learned, and she was amazingly helpful by both listening and gently challenging me. She pointed out that, although right now I’m primarily interested in physician well-being, medical students typically change their minds about long-term career choices several times during medical school, and she advised me to keep my eyes open for other options at all times. Anyway, despite that warning, which makes a lot of sense to me, the end result was that I accepted the offer of going to State University’s medical school. That’s where Dr. Evansly works, and as an add on, she has already volunteered to be one of my mentors and has shown me several possible scholarships I can apply for so I might have less student debt long term.”
“That’s great! Congratulations,” said Claire. “It must be great to have such good contact with a faculty member before you even go to medical school. Do you have any other connections there already?”
“Actually, I do,” Luis replied. “The school has a system of colleges, with about one-quarter of each year belonging to each of the four colleges, so when you start you have a built-in student support system that runs through all 4 years of the course. I’ve already had several students contact me from my college and have met a couple of them for coffee. They’ve given me the lowdown on what I need to do to prepare for the first year, and as a result, I’m already doing extra reading in biochemistry to prepare myself, because that’s my weakest subject. I hope I’m not putting you guys off, but medical students still have to master the precise details of all the liver enzymes and the Krebs cycle to be a doctor. I guess one of my objectives for school could be to try to improve the curriculum so it includes useful topics that doctors have to know in order to practice, such as taking care of their own health. That would make the experience of medical school much more useful and relevant and would provide real-life tools to deal with stress and very hard work.”
Luis looked around the room, ready to finish his talk. “You know, preparing this talk for you guys has been very helpful to me. I think I may look at doing some sort of review of what might make a good curriculum for anyone who wishes to be a ‘doctor’s doctor.’ I think that would have made both my parents very proud. I wish they could have seen what I’m doing.”
Commentary
Three major themes of this scenario are important. First, what strengths or evidence of resilience and motivation do schools look for in applicants that will ensure chosen students have long-term success as physicians? The corollary is what, therefore, do students have to demonstrate to obtain admission to medical school? A related issue is how can students carefully curate their online presence and their offline resume over several years to ensure that they minimize possible “red flags” that might obstruct their admission?
Second, what programs do medical schools have to support the well-being of their students? We know from the research of Brazeau et al. (2014) that, at entry to medical school, medical students are more resilient than age- and gender-matched nonmedical graduate students. Yet within 2 years they have higher rates of depression and burnout than equivalent control subjects, and these high rates persist throughout residency and for at least 5 years beyond (Dyrbye et al. 2014). What goes wrong, and how can this be prevented?
Third, despite Luis’s obvious motivation and intelligence and his demonstrated capacity to overcome adversity, it is evident that he is someone who is vulnerable to becoming burned out or psychiatrically ill in the future. He may need extra support and help during his training as well as later on in his career. How do we know this? Luis has a strong genetic predisposition to depression, through his father’s suicide, his mother’s likely chronic depression (and diabetes as a second chronic illness), and his own possible recent episode of depression. Just as importantly, he has a background characterized by adverse childhood experiences (ACEs), which we know are related to an increased risk of poor mental and physical health outcomes in adulthood. Were he to take it, Luis would score more than 4 on the ACE Scale (Gilbert et al. 2015) as a consequence of his traumatic childhood. This cutoff score is associated strongly with the likelihood of the eventual development of chronic medical and psychiatric disorders in adulthood. In summary, Luis is vulnerable both biologically or genetically and from a lifestyle and experiential perspective. What are the implications of this for his future career as a physician despite his capacity to successfully jump the high bars related to medical school admission?
Taking the first theme in this chapter, what do medical schools look for in applicants that, they believe, will create successful doctors? Luis learned the importance of self-care and well-being years before entry to medical school but, during the entry process, also discovered how relatively little medical schools, residencies, and postgraduate academic programs focus currently on this topic. Medical schools’ admissions teams use many differing data points to help them predict which students will cope well with the ardors of medical school and residency training and become successful physicians and which will not. These include not only students’ performances on the MCAT and their grade point averages in college but also their capacity for self-care and resilience, which, although often demonstrated by students, is harder to objectively measure. At a broader level, it is well known that doctors need to be both caring and organized to succeed professionally. As a result, medical school admissions committees frequently look for personality characteristics in students that show evidence of some dependency and compulsiveness, both traits that unfortunately can make the individuals vulnerable to developing psychiatric disorders if present to an excessive level. At the same time, they are looking to exclude students who have little empathy with, or sympathy for, other people.
Some interesting studies of the personalities of medical students examined these issues in more detail. A recent large study of 808 medical students at the University of Queensland, Australia, published by Eley et al. (2016) identified two distinct personality profiles. Profile 1 (“resilient”) characterized 60% of the sample and was distinguished by low harm avoidance combined with very high persistence, self-directedness, and cooperativeness. Profile 2 (“conscientious”) showed more harm avoidance and less persistence, self-directedness, and cooperativeness. The research team concluded that both profiles were indicative of mature and healthy personalities, but the combination of traits in Profile 1 was more strongly indicative of well-being and resilience.
So what do medical schools who have a demonstrated interest in helping students with their own self-care look for in prospective medical students, and what could Luis have told his audience if he had fully understood the perspective of most schools? Morris (2016) summarized five key attributes that lead to successful medical school entry:
Communication skills: Medicine is dependent upon the communication of ideas, concepts, and orders.
Presence: This trait is key when effectively speaking to colleagues and patients. Be present by focusing attention on the other individual when talking.
Critical thinking: This is integral as the physician assesses volumes of data to quickly form a working conclusion, using deductive reasoning and inferences based on knowledge and experience.
Compassion: Compassion is more than kindness and civility; it’s authentic sympathy for self, patients, colleagues and co-workers irrespective of race, class, creed or personal behavior.
Resilience: This is what gets you through those moments when seemingly everything has gone wrong. For a successful career and life, discover healthy coping mechanisms that work best for you to perform optimally.
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