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In Reply

Prober, Charles G. MD

doi: 10.1097/ACM.0000000000002996
Letters to the Editor

Senior associate vice provost for health education, Stanford University, Stanford, California;

Disclosures: None reported.

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In Reply to Highet et al:

I thank the authors, medical students from University of Michigan Medical School, for their reflections on my Invited Commentary. I agree that residency is not “an end point,” but it is much more than a “stepping stone.” It represents 3 to 7 years of intense and sometimes stressful training during a time when personal relationships are deepening, families are being started, and rates of mental anguish, including burnout and depression, are prevalent.1 Students must consider how their future training programs will address their personal needs. The trainee will determine his or her future success, not the program. This is not idealism; this is realism.

The authors note that they prioritize what program directors (PDs) value across specialties: United States Medical Licensing Examination (USMLE) scores and clerkship grades. I have previously discussed my concerns about the overemphasis on USMLE scores and acknowledged that these scores likely will continue to have outsized weight2 in residency selection. But there is hope. In March 2019, the Association of American Medical Colleges, American Medical Association, Educational Commission for Foreign Medical Graduates, Federation of State Medical Boards, and National Board of Medical Examiners convened a stakeholder conference to develop recommendations mitigating the ill effects of USMLE scores and the “broader system of transition” from medical school to residency.3

Because performance in clerkships mirrors performance during residency, I believe that it is appropriate for PDs to heavily weight clerkship performance in their selection process. I disagree that programs do not value teamwork and intellectual curiosity in their assessment of future residents. Both traits often are evident (or not) during clerkships.

I agree that away rotations are costly and may be impossible for some students. Therefore, institutions should develop programs, like the one my colleagues and I developed, to enable students with financial need to participate. My colleagues and I introduced the Stanford Clinical Opportunity for Residency Experience Program several years ago.4 Students with financial need receive housing and a $2,000 stipend for a clinical rotation at Stanford. This program has succeeded in identifying many extraordinary candidates who we were fortunate to recruit. These residents have enriched our institution in many ways, including enhancing the diversity of our training programs. Decisions to recruit these candidates were made without regard for their USMLE scores.

I agree with most of the authors’ points, and I feel their pain as prospective residents. I continue to hope that in their search for the best match, they seek programs that best fit their professional and personal needs.

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1. Roberts LW. Understanding depression and distress among medical students. JAMA. 2010;304:1231–1233.
2. Prober CG, Kolars JC, First LR, Melnick DE. A plea to reassess the role of United States Medical Licensing Examination Step 1 scores in residency selection. Acad Med. 2016;91:12–15.
3. InCUS Planning Committee. Summary report and preliminary recommendations from the Invitational Conference on USMLE Scoring (InCUS), March 11–12, 2019. Accessed September 4, 2019.
4. Stanford Medicine. Stanford Clinical Opportunity for Residency Experience Program. Accessed September 4, 2019.
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