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Practical Implications of Compassionate Off-Ramps for Medical Students

Aagaard, Eva M., MD; Moscoso, Lisa, MD, PhD

doi: 10.1097/ACM.0000000000002569
Invited Commentaries
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Attrition from medical school remains uncommon even when a medical student performs poorly, has a change in interests, or experiences an unexpected life event that alters his/her ability to succeed as a physician. In this issue, Bellini and colleagues describe the scope of this problem and make recommendations to support the implementation of compassionate off-ramps for students. These recommendations include enabling ongoing assessment of commitment to career path via a professional identity formation curriculum; implementing competency-based education and training to identify struggling learners; using career advisors and coaches who understand alternative career pathways; providing credit or credentials for competencies already achieved; requiring financial counseling and supporting debt forgiveness; and requiring schools to report on their remediation programs and handling of debt. In this Invited Commentary, the authors describe a representative student—a composite of several students they have counseled whose medical school paths have been impacted by poor performance, unanticipated life events and stressors, changing career interests, and/or physical and mental health issues—who may have benefited from these recommendations. The authors elaborate on Bellini and colleagues’ recommendations and describe what they think would be necessary to ensure that the recommendations effectively meet the goal of providing compassionate off-ramps for students in need. The authors describe the potential impact of the recommendations on the representative and similar students. Although this impacts a small proportion of students, the recommendations would help schools achieve the moral imperatives of humanistic care for students while honoring the social contract of the medical profession.

E.M. Aagaard is Carol B. and Jerome T. Loeb Professor of Medical Education and senior associate dean for education, Washington University School of Medicine in St. Louis, St. Louis, Missouri; ORCID: https://orcid.org/0000-0002-5773-0923.

L. Moscoso is associate professor of pediatrics and associate dean for student affairs, Washington University School of Medicine in St. Louis, St. Louis, Missouri.

Editor’s Note: This is an Invited Commentary on Bellini LM, Kalet A, Englander R. Providing compassionate off-ramps for medical students is a moral imperative. Acad Med. 2019;94:656–658.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Eva M. Aagaard, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave., Campus Box 8073, St Louis, MO 63110; telephone: (314) 362-7874; e-mail: aagaarde@wustl.edu; Twitter: @AagaardEva.

It is the second Monday in March, also known as “No Match Day.” T has just learned that he did not match. T has been in medical school for seven years. He was the victim of a violent assault in his first year, which resulted in a several-months-long medical leave of absence. He reentered into a decelerated curriculum, which extended the preclinical curriculum from two to three years. Since the assault, he has suffered from anxiety, posttraumatic stress disorder, and intermittent depression. Exams and other stressful situations worsen his symptoms. He failed two exams during his preclerkship phase but was able to pass both on the second attempt. He delayed taking the United States Medical Licensing Examination Step 1 by six months. He ultimately passed with a score one standard deviation below the national mean. T had a total of four leaves of absence during the clerkship phase. He delayed taking the shelf exams in his surgery and pediatrics clerkships multiple times after failing and successfully remediating the medicine shelf exam. After the medicine shelf exam failure, he had neuropsychological testing and was given accommodations for the other shelf exams for anxiety. His transcript reveals all passing marks in both the preclerkship and clerkship phases. Some of his narrative evaluations reflect concerns about his commitment and engagement, while others describe him as an empathetic, caring young physician. T has said repeatedly that he is committed to being a physician.

This story is a composite that is representative of several students we have worked with over the last 15 years whose paths through medical school have been impacted by poor performance, unanticipated life events and stressors, changing career interests, and/or physical and mental health issues. Most presented as struggling students, performing poorly in a course or clerkship. Others were flagged for professionalism concerns—failure to show up, tardiness to required activities, late assignments, or not completing required tasks or procedures. Some came to our attention through other students. The most successful sought out help early in the process and actively engaged available resources and support systems. A small portion of these students experienced a significant setback during medical school, yet they continued and we allowed them to continue. And some—the “unmatchable”—graduated with no hope of ever practicing medicine. These stories are not common, but when students reach commencement but are unmatched, they are devastated, and we as medical educators are left to wonder what we could have done differently.

In this Invited Commentary, we describe how Bellini and colleagues’1 recommendations to enable the use of compassionate off-ramps (i.e., “options to leave medical training without compromising one’s self-esteem or incurring unmanageable debt”) may have improved the outcomes of students like T and those we have counseled. We use our shared experience and the literature where available to elaborate on these recommendations.

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Recommendation: Implement Competency-Based Education and Training to Identify Struggling Learners

Competency-based education and training (CBET) calls for the development of a program of rigorous assessment to ensure that all trainees meet predefined standards of acceptable performance prior to progression to the next level of supervised or independent practice.2 At least some data suggest that implementation of CBET can result in early identification of learners who are at risk.3,4 For those involved in remediation, CBET also provides a schema for diagnosing their deficits and developing a strategy to address them.5,6 Importantly, for remediation to be effective, significant structures and resources are necessary, including the availability of individuals with training in remediation strategies, neuropsychiatric testing, and psychologic counseling, as well as the availability of learning specialists. Even with such resources, both learners and institutions must define when the costs for the student and the school are no longer worth the potential benefits of continuing the remediation process. Factors such as future ability to match into a desired specialty; alignment of desired career path with skills and abilities; and the time, accruing tuition, and various costs of the remediation process should all be considered. Ultimately, for CBET and early identification of struggling learners to be an effective mechanism for fostering compassionate off-ramps, the institution must have clear and consistent processes by which decisions to continue in the curriculum are made, usually through a promotion committee that understands the consequences of these decisions for the student, the institution, and society.

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Recommendation: Enable Ongoing Assessment of Commitment to Career Path via a Professional Identity Formation Curriculum

We believe this recommendation is important for all students, not just those who are struggling. First and foremost, a student’s commitment to a successful and satisfying career in medicine must be genuine and originate from his or her own desires. Providing structures that allow students to periodically identify their purpose and ensure that it aligns with the career path they have chosen is critical to their long-term success.7 Moreover, it is the educational institution’s responsibility to help them identify their passions and align their skills and interests with potential career options.8 Longitudinal professional identity formation curricula would be a critical component of this responsibility throughout the student’s training. Descriptions of how professional identity evolves during training and how schools can effectively incorporate intentional training in professional identity formation have been published; they include reflective writing, communities of practice, white coat and other ceremonies, oath building exercises, and intentional role modeling and coaching.9–11

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Recommendation: Use Career Advisors and Coaches Who Understand Alternative Career Pathways

Although professional identity curricula are essential aids, it is important to supplement these with individualized advising and coaching that places the students’ goals and interests in the context of their abilities and scholarly record. Although this may seem straightforward, it is anything but. It requires a knowledge of the student and his or her performance, a deep understanding of the profession and desired specialty, and a working knowledge of the matching process and available residency programs. A small group of individuals may hold all these skills, but more commonly, students are reliant on a group of faculty or staff to guide them. Adding one or more individuals who understand alternative career pathways in areas such as industry, technology, and education would clearly be a valuable addition. Additionally, although creating formal processes for advising and coaching may help ensure that students have access to the resources they need, ultimately, effective advising and coaching requires the creation of trust and transparency between the student and his or her advisors. For example, specialty-specific advisors may not have a clear picture of the student’s viability in their specialty if the student does not disclose his or her potential shortcomings. Finally, for this to serve as an actual off-ramp, advisors and coaches must have the communication skills necessary to convey the sometimes-difficult news that a student’s goals are not aligned with his or her skills or abilities. In our experience, this conversation with the student must occur multiple times and with multiple people for the student to hear the message and consider choosing an alternative path.

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Recommendation: Provide Credit or Credentials for Competencies Already Achieved (e.g., Certificates, Master’s Degrees)

Students admitted to medical school are almost universally exceptional individuals. They deserve the opportunity to try alternative strategies to be successful. Evidence suggests that most medical students can become minimally competent at a given skill; it just may take them longer, or they may need an alternative learning strategy to get there.12 It may also take them longer to develop self-awareness of goals, interests, and passions. Many medical students experience other pressures and expectations around success from their parents, family, community, culture, and/or themselves that can cloud their self-awareness. It can take time to overcome these pressures even when supported through effective professional identity formation curricula, iterative feedback, and coaching. Meanwhile, students are accruing important knowledge and skills, as well as debt. Although it is unclear what value a credit or credential such as a certificate or master’s degree may hold, it provides evidence of advanced knowledge and a commitment to completing a program in the medical sciences. Schools that implement programs to allow students to receive such credits or credentials for the competencies they have achieved must have clear descriptions of what qualifies a student to receive such a certificate or degree for it to have meaning that is translatable to other professions. Again, an advisor or coach with knowledge of alternative career paths that may value such a certificate or degree would be essential for this recommendation to be successful.

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Recommendation: Require Financial Counseling and Support Debt Forgiveness

Medical student debt is a significant issue for most students who plan to practice medicine and is a potential disaster for those who are unable to practice medicine or who transition to an alternative career path. According to the Association of American Medical Colleges (AAMC), 75% of medical students graduate with debt, and, in 2018, the median debt after graduation was $200,000.13 The national dialogue around reducing student debt has reached a fever pitch with recent announcements that Columbia University and New York University have moved to debt-free and tuition-free, respectively, models. Although this is exciting news for students at those universities, most medical schools will not be able to follow suit. Moreover, at least some of those students will likely still have loans for living and other expenses accrued during their training. All students who accept loans benefit from financial counseling that provides a realistic understanding of their future earning potential and the impact of their debt on their future spending and savings. Financial counseling is especially critical for those students who, by their own choice or other forces, transition out of a physician career path. Debt forgiveness, which may be possible for some schools, would certainly allow students to make decisions about their future without the weight of accumulated debt on their shoulders.

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Recommendation: Require Medical Schools to Report on Their Remediation Programs and Handling of Debt

Reporting on the processes for remediation and mechanisms by which schools manage the debt of students that use off-ramps could provide a valuable service for all medical schools. Specifically, sharing best practices and mechanisms by which schools are able to implement all of the recommendations discussed here would allow institutions to learn from each other. Because the number of students at any single institution to whom these recommendations apply is likely small, such a collaborative reporting process may also facilitate multisite studies to evaluate the effectiveness of the various programs implemented. Bellini and colleagues1 suggest that these reports be made to the Liaison Committee on Medical Education (LCME) and that the LCME “[consider] debt forgiveness a marker of excellence.” The LCME, however, is an accreditation body whose primary role is to determine whether a medical education program meets established standards. Because these recommendations are not yet well studied and are resource intensive, an alternative convener, such as the AAMC, may be more appropriate. Furthermore, lauding those schools that are financially capable of forgiving debt would likely advantage private and more selective schools.

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Conclusion

What if T went to an institution where these recommendations were followed? Early identification of the impact of T’s anxiety on his test performance and in the clinical setting may have allowed for earlier implementation of accommodations or enhanced management of his symptoms through additional medical care. Clear evidence of failed competency in specific domains may have provided valuable data for T, allowing him to make a more informed decision about his career path. Conversations about his options would have been more productive if he had a clear vision of his professional interests and how his challenges would be supported or exacerbated by the various career paths he was considering. A longitudinal advisor or coach whom he trusted and who understood all the aspects of his performance, his personal struggles, his career interests, and their alignment with his goals and skills could have helped him to potentially avoid not matching. Perhaps that advisor or coach would have been able to help him explore other specialties that would be better able to meet his unique needs. Or perhaps he would have chosen to take a different road altogether. Certainly, he has now accrued a significant amount of debt. The opportunity for debt forgiveness and a credit or credential for his hard work and accomplishment would, at a minimum, open the door for a conversation about other possible career paths and how they may fit with his professional identity and goals.

Several schools have started implementing components of these recommendations, but it is the combination that ensures the highest probability of achieving the best possible outcome—learners who go on to a career of meaning for them with an opportunity for lifelong success. We will be working toward implementing all of these recommendations at our institution, and we challenge others to do the same. We believe that although this call to action impacts a small proportion of the overall medical student body, the recommendations would help medical schools to achieve the moral imperatives of humanistic care for students while honoring the social contract of the medical profession.

Acknowledgments: E.M. Aagaard thanks Drs. Jeannette Guerrasio, Maureen Garrity, and Terri Blevins for their indispensable contributions to her understanding of remediation and student counseling.

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References

1. Bellini LM, Kalet A, Englander R. Providing compassionate off-ramps for medical students is a moral imperative. Acad Med. 2019;94:656–658.
2. Gruppen LD, Ten Cate O, Lingard LA, Teunissen PW, Kogan JR. Enhanced requirements for assessment in a competency-based, time-variable medical education system. Acad Med. 2018;93(3 Suppl):S17–S21.
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13. Association of American Medical Colleges. Medical Student Education: Debt, Costs and Loan Repayment Fact Card 2018 (PDF). 2018. Washington, DC: Association of American Medical Colleges; https://store.aamc.org/medical-student-education-debt-costs-and-loan-repayment-fact-card-2018-pdf.html. Accessed January 11, 2019.
© 2019 by the Association of American Medical Colleges