“Going to medical Spanish class really isn’t worth my time. I’d rather use the time to do research,” one of my classmates told me during the first week of my first year of medical school.
Such a comment was my introduction to the publish-or-perish environment that is increasingly pervasive amongst medical students. Before then, I had known publish-or-perish as something for those seeking tenure at universities. I believed that medical school was a place where I would be learning about the human body and learning bedside manners through classes like medical Spanish that had patient-actors for students to interact and communicate with.
But as my first year went on and I saw more and more classmates skip patient-facing classes to spend time conducting research, I realized how much the publish-or-perish environment also applied to medical students like me who are hoping to get into residency programs.
It’s what some are calling the residency research arms race, in which medical students feel the need to publish more and more research articles to differentiate themselves from their peers on their residency applications.
I understand why my classmates feel research is so important. After all, research skills help physicians keep up to date with the latest treatments and guidelines.
Research also reflects, in a quantifiable way, an applicant’s interest in a field. Residency program directors began valuing research more after the U.S. Medical Licensing Exam (USMLE) Step 1, the first of three exams medical students must take to acquire a medical license in the U.S., changed from a numeric score to pass/fail. The elimination of a numeric score for the plethora of highly qualified candidates for limited residency spots means program directors have a harder time differentiating between candidates.
Research, and the volume of the applicant’s scholarly output, has become the second most important aspect of a residency application, and what many residency programs use to distinguish applicants from one each other. This is why the average number of publications medical students have under their belts by the end of medical school has skyrocketed in the past few years and why applicants for certain specialties, like neurosurgery, average up to 29 research activities — a number higher than many Ph.D. candidates publish by the end of their programs.
I believe that the the research arms race has detrimental ramifications for both physicians and their patients.
First, the sheer number of research activities that medical students need to be competitive in sought-after specialties, such as dermatology and orthopedic surgery, pushes them to take research gap years during medical school and use the time to publish research. These research years are often underpaid or unpaid, creating a barrier for students like me from less-affluent backgrounds.
I felt these pressures acutely during my first two years in medical school. I did not have a specialty in mind when I started med school, and wanted my clinical experiences to inform such an important decision. The residency arms race, however, forced my hand to cross off certain specialties — not because of my lack of interest, but due to my lack of financial resources to take a research year. I believe such structural barriers ultimately limit physician diversity, and will only worsen health outcomes for patients from historically marginalized communities.
Second, the increased emphasis on publication has led to a push for medical students to produce junk studies — studies that often are never cited again by other researchers. I have had several classmates offer me authorship on papers that would have little scientific impact as long I contributed a few paragraphs and a share of the money for a “pay-to-publish” journal. Such junk studies were guaranteed to add a line on our resumes, but would do little to add to our understanding of the world of medicine. They only further reinforce the publish-or-perish environment and a toxic culture which incentivizes publishing without full due-diligence or through data manipulation.
The toxic publication culture has extended beyond pay-to-publish journals, as can be seen by retractions of scientific papers in major journals by researchers from Stanford, Harvard, and a variety of other institutions.
Patients ultimately pay the price for junk publishing as they lose trust in the medical system or have to wait longer for effective treatments.
Third, the focus on research does not align with the skills that are most important for making good physicians. The current residency application system values applicants with research skills highly over so-called soft skills like communication and team building. These skills aren’t emphasized in residency applications because they are hard to capture through numeric values and personal statements, even though research has demonstrated that the patients of physicians with better communication skills have better health outcomes. Additionally, the patients of some physicians who split their time between seeing patients and nonclinical responsibilities such as research and administration have higher mortality rates, compared to those seen by physicians who are clinically focused and solely see patients. Why? Researchers have hypothesized that clinically focused physicians perform risky procedures at lower rates and, ironically enough, are more up to date on clinical guidelines and skills compared to their research-focused counterparts.
Writing in the Journal of Graduate Medical Education, two physicians proposed capping the number of research activities that can be mentioned in residency applications. Such a limit would incentivize students to focus on quality investigations and disincentivize the use of sheer quantity to stand out from other applicants. It would also reduce the need for students to take the research gap time required to keep up with the research arms race, thereby removing barriers for students from low-income backgrounds to pursue certain specialties. The limit would also slow junk study publishing by medical students and encourage them to return to focus their efforts on skills that matter for patient care.
I am not writing this essay because I dislike research. Quite the contrary: I love the intellectual curiosity and critical thinking skills needed to be a successful researcher. But for me, the measure of what makes a good medical student and future physician should not be how many publications they have, but how well they understand and care for their patients.
Anmol Shrestha is a second-year medical student at the California University of Science and Medicine.