“Good morning, Dr. Holmes. It’s so nice to meet you. Tell me, how will the medical school assure me that I can author 25 publications so I can secure a residency position in neurosurgery?”
While the details are altered, this type of question from a first-year medical student visiting the student affairs office is not exaggerated, and variations of this encounter have increased at medical schools nationwide. Students have read the highly available national “data” on match rates in competitive subspecialties. They know what they “have” to do to match. But this comes with significant consequences for future doctors and patients alike.
It’s time to alter incentives to keep medical students’ central focus on the core curriculum and clinical care.
What’s Driving the Research Arms Race?
A confluence of factors is driving this paradigm. First, many opportunities for academic distinction have evaporated with the introduction of pass-fail grading of the USMLE Step 1 exam, pass-fail grading of preclinical courses and clerkships, and elimination of Alpha Omega Alpha/AOA honor society chapters. Second, students have developed elevated expectations for future earnings and lifestyle, leading to greater interest in “competitive,” highly remunerated specialties. And finally, applicants and residency programs have greater access to detailed data regarding the characteristics of residency applicants, increasing the focus on measurable achievements.
All together, these factors have substantially altered the residency application landscape, and extremely bright medical students are well aware of what this means for strategically focusing their time and energy.
The Impact
With medical students’ increased focus on research to distinguish themselves when applying to prestigious residencies, attendance and engagement in courses — and even rotations — has plummeted. Then, there is the issue of what it means for the quality of the research being conducted if “distinction” is based on how many papers one is listed on. Unfortunately, it’s mostly bad news for everyone: for medical students, for faculty members, for research teams, and for the most important people in the research enterprise — the patients and communities who benefit from new discoveries.
When academic medicine is not primarily focused on meeting the needs of the patients, families, and communities we serve, it is time to make some changes.
To be sure, research is fundamental to academic medicine. Patients specifically seek care in academic health systems so they can benefit from new advances and be cared for by physicians who are leaders in both clinical practice and innovative research. The medical student experience can certainly be enhanced by an appropriate degree of engagement and the creativity, discovery, and service that comes with meaningful research participation. But problems arise when the incentives skew toward “boxes to be checked” for career achievement.
Things get icky — fast — when research becomes about presentation and publication numbers. Over-incentive to publish has been shown to lead to sloppiness, overly dramatic conclusions, and “pollution” of the literature with faulty findings that potentially harm patients. For a medical student with nascent research skills and a full-time core curriculum, a goal of 25 publications and presentations in the 3 years between matriculation and residency application is clearly untenable — and frankly impossible.
It’s important to look at this from the vantage point of our students: how would your anxiety, sleep quantity, and overall well-being fare if you were seeking to accomplish this level of academic productivity on this insanely compressed timeline?
Residency program directors also dislike the situation. They do not want to recruit residents who have spent their time in medical school engaged in research at the expense of dedication to the core curriculum, patient care, and their personal health. One dermatology program director told me, “By the time they start with me, they are already burned out.”
We should celebrate the successes of student research and hold dear the special relationships students develop with faculty and other mentors. But there is also an ugly underbelly: the frustration of students who feel abandoned when a project doesn’t go as expected or when team members don’t adhere to timelines. There are also countless stories of faculty who do not hear from students they are counting on for parts of a research project when the student decides to move on to a different field. These situations are not helping us build thriving academic communities, but rather further eroding trust.
If reading about the current situation has not yet stirred you, let me add another consequence to the mix: the outsized emphasis on medical student research exacerbates inequities.
Typically, research opportunities are most accessible to those who attend the most selective medical schools (with the most research-intensive faculty) and those students who can network via personal, faculty, or family connections. Yet, the inequities run even deeper: Who has fewer economic barriers to attending a conference to present their work? Who has the funds for a pay-to-publish journal to get a manuscript in print? Who need not worry about investing in an additional unfunded “research year” during an already costly MD program? The students who come from means.
Finally, those specialties with the highest “publication numbers” are the same fields where there is already less diversity in the population of practicing physicians. The added pressure to conduct more research as a medical student will only promulgate and worsen the problematic status quo.
Of course, when we step back and consider the situation critically, it’s clear that the available “successful applicant” publication numbers are grossly overinflated because they are simply counts of what students list on their residency applications. Although some individuals have demonstrated that, in reality, their matched applicants have authored only a median of somewhere between zero and two publications, those of us engaged in medical student advising are having a hard time convincing our students of this when the colorful “publication” graphs are so readily accessible.
Shifting Incentives
What should be done? The residency application systems should limit each applicant’s publications and presentations to their “three most important” — just as it already sets firm limits for other aspects of the application. This will restore sanity and equity, renew the centrality of the core curriculum, improve student-faculty relationships, and allow research to be an appropriately optional, small, and enjoyable part of the educational experience.
Back to our beacon: the patients. Our students’ future patients do not benefit from the current educational status quo. They need their doctors to possess sound knowledge of physiology, anatomy, pharmacology, health equity, and medical ethics. They need them to focus on maintaining compassion and developing expert communication skills.
They desire young doctors with sound clinical reasoning, a working knowledge of quality assurance and patient safety, and a good measure of stamina and dedication. Some research to enrich their medical education and benefit patients? Absolutely! But not a medical student research arms race that disincentivizes deep engagement with clinical medicine and pollutes the scientific literature with poor-quality scholarship and unimportant discoveries.
It’s time to stop the madness and place a firm cap on residency application publication and presentation numbers — because our medical students deserve equality of opportunity and personal well-being, and our patients deserve outstanding clinicians.
Alison Volpe Holmes, MD, MS, MPH, is an associate professor of pediatrics at Geisel School of Medicine at Dartmouth, and served in the Office of Student Affairs from 2018 to 2024. Holmes is a past board member of the Academic Pediatric Association and currently serves on the general pediatrics examination committee of the American Board of Pediatrics.
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