Med School Uncensored
The Insider’s Guide to Surviving Admissions, Exams, Residency, and Sleepless Nights in the Call Room
Special Words for Special Groups: Age, Gender, and Disabilities
Life Experience and Non-Traditional Students
According to the Association of American Medical Colleges (AAMC), the average age of matriculating U.S. medical students in 2014 was 24. It was the same when I started med school in 2006; I was 26 at the time. The phrase non-traditional student is often used to describe students starting med school at an older age, especially if they have experience in another career prior to applying to medical school. More broadly, non-traditional students come into medical school by a path other than the usual trajectory of college immediately followed by med school.
There are benefits to having real-world experience prior to starting medical school. A previous career can bring unique perspective to the frequently homogenous backgrounds of incoming medical students. The maturity that comes with age and experience can add stability to one’s commitment to becoming a physician. If nothing else, having some time to explore non-medical interests and pursuits before medical training can result in a better-rounded physician.
Starting medical school more than a couple years after college also has its drawbacks. Seven to eleven years is an extremely long time in anyone’s life. That’s four years for medical school plus three to seven years for residency and a possible fellowship—depending on the chosen specialty. Add on additional time if prerequisite science classes must be completed before med school. A person can change immensely in that time, and everything else in the world changes, too. It’s difficult for anyone in their 20s or early 30s to fully appreciate the gravity of the time commitment required to become a doctor.
I decided to pursue a career in medicine when I was 23. After going back to school to complete science perquisites and taking the MCAT, I enrolled in med school at the age of 26—not too far off the average age of 24. Being a bit older with a prior career in business and computer programming, I was at least somewhat in the non-traditional camp. At the time, I was confident I understood what it meant that I wouldn’t be done with medical training until my mid-thirties. But now that I am done with medical training and am in my mid-thirties, I’m not sure I really appreciated how much of my life I would sacrifice to become a physician. To be sure, I don’t have any regrets. But I do think I underestimated the Rip Van Winkle effect.
Even for traditional students starting medical school in their early 20s, suddenly arriving in the “real world” of mortgages, families, and retirement accounts in one’s early 30s can be unsettling. Friends from high school and college may have young teenagers at home and are purchasing their second home, while you’re still trying to figure out what a 401(k) is. The frustration can be even greater for students entering med school even later in life.
Being an older-than-average medical trainee also presents physical challenges. Even with ACGME work hour restrictions in place, residency often means working thirty hours straight with no sleep, being on one’s feet much of the time, having to make life-and-death decisions throughout the night. That’s hard to do at the age of 25. It’s much harder at the age of 35, and I can’t even imagine how I’m going to feel after a 24-hour call in ten or twenty years.
I knew a few students at my medical school who matriculated in their late 30s. It’s certainly a feasible proposition, but residency during one’s 40s can’t be easy. If you’re currently in your 30s or beyond and are considering applying to medical school, realize that it’s not just a mental challenge that you will experience. Your stamina and physical abilities will also be stressed—very frequently during some months of residency. Just make sure you know what you’re getting yourself into!
Mental challenges also abound for non-traditional students. When I was 31 years old during my second year of residency, an attending physician said she always recommends to students and residents past the age of thirty to allow additional time for studying because she has found they frequently need to read things multiple times to remember them sufficiently. Though I was probably insulted at the time, I definitely noticed that my rote memorization skills were not as sharp in med school as they had been during high school and college. Indeed, studies have shown that some aspects of age-related cognitive decline being in healthy, educated adults as early as the mid-20s. One such study found that rote memorization abilities peak at age 22.
It’s certainly possible to start medical school later in life. In fact, there are many benefits to exploring other careers and interests prior to committing to medicine—for both future physicians and their patients. But it’s not always an easy path! The physical and mental challenges are often more difficult than for younger peers. And non-traditional students sometimes come out the other end of the medical education tunnel feeling much older than when they started.
Gender Equality and Differences
According to the AAMC, women made up 47.8% of matriculating medical students in 2014. That was up 0.6% from the prior year but down 1.8% from 2003. Overall, the last decade has seen a pretty consistent 52-48 split for men versus women. The ratio of med school applicants is roughly the same. This is a sharp contrast to three decades ago: in 1982 only 31.4% of matriculating med students was female.
I have two daughters, born in 2011 and 2013. I have no idea if either of them will be interested in pursuing a career in medicine. But if one of them does someday tell me she wants to become a physician, I know exactly what I would do. First, I would give her a copy of Med School Uncensored! If she reads my book and still wants to go to med school, I would encourage her wholeheartedly and prepare her as much as possible. Many female colleagues from training and practice have been among the best physicians I know. In fact, a 2016 study by Harvard researchers found patients treated by female doctors had lower 30-day mortality and readmission rates after hospital stays.
Still, I would tell my pre-med daughter some things that I would not tell my hypothetical son in the same situation. Even in our post-gender society in which girls have blue lunchboxes and boys can play with dolls, there are still biological realities that female physicians must face that are not as relevant to their male counterparts. Female fertility peaks during the 20s, which cruelly coincides with the decade of life during which most future female physicians are engrossed in the decade-long journey of med school, residency, and possibly fellowship.
According to the American Society for Reproductive Medicine (ASRM), a healthy, fertile 30-year-old woman has a 20% chance of getting pregnant each month she tries. By the age of 40, that chance is less than 5%. Because women are born with all the eggs they will ever have, the quality of eggs declines over time, as does their quantity. This means increased maternal age brings not only more difficult conceiving, but also a greater risk of birth defects. One of the most common genetic disorders related to maternal age—and paternal age, though to a lesser degree—is Down Syndrome. In the general population, the chances of a 20-year-old woman giving birth to a baby with Down Syndrome are roughly 1 in 1,450. By the age of 35, that risk has more than quadrupled to 1 in 350. By the age of 45, the risk is about 3%.
Men aren’t completely immune to the realities of human reproduction. But for better or worse, men usually continue to produce sperm well into their 60s and beyond. The quantity and quality of sperm do decrease with age, but this usually doesn’t occur until many years after the average male physician finished medical training. By contrast, female doctors often find themselves with a very limited timetable after completing residency and fellowship if they are interested in starting a family.
There is no easy advice to give to women regarding this topic. In-vitro fertilization (IVF) is increasingly common as couples delay marriage and childrearing. But it is not a panacea. By the age of 40, IVF success rates are generally less than 20% per cycle. That comes with a price tag of $20-40,000 per cycle—and frequently a great deal of emotional and physical stress. Freezing one’s embryos (produced either with a male partner or donor sperm) does improve chances of successful IVF, but this decision must be made—and paid for—during one’s 20s or early 30s for best effect. Finally, egg freezing is a newer technology that has been helpful for some women—but success is not guaranteed and is likelier when eggs are retrieved at a younger age. These are decisions and actions that a woman must make before her mid-30s. Considering that most women enter med school in their early 20s and don’t finish training until about a decade later, that can be a difficult feat!
Perhaps my hypothetical pre-med daughter will have better options and more advanced technologies available to her by the time she is making these decisions. But for current readers, the best advice I can give is to at least consider all of the above. At least keep it in the back of your mind. I know that in one’s early 20s, life and options seem infinite—and family planning may be far from one’s mind. But realize that once you start med school, you will get sucked into an all-consuming education and training process that will leave you little time to tend to the rest of your life. Then you will suddenly emerge—roughly a decade older—with all of life’s other decisions still waiting to be made. There are no easy solutions, but it at least helps to be aware of the problems.
Mental and Physical Disabilities
In general, I think anybody with a mental or physical disability who can go through the academic rigors required to gain admission to medical school probably has figured out how to navigate that disability sufficiently to succeed in medical school and have a successful career in medicine. Indeed, I came across several classmates in med school and residency with a variety of disabilities, including learning and attention disorders, depression, nerve entrapment, and neuromuscular disease. I was thoroughly impressed with all of these people and have no doubt that they will do extraordinarily well in their careers as physicians.
However, I think there is a limit to the types and severity of disabilities that should be considered acceptable for admissions to medical school. A med school admission committee may have the best intentions in mind by accepting somebody who is academically spectacular but has some disability that may impede his ability to succeed in medical school. They may think everyone should be given an honest chance and that there’s no harm in letting him try.
Unfortunately, the reality isn’t that simple. Unless a scholarship is on the table, the student debt ticker starts moving on the very first day of medical school. Since the first two years of med school are spent almost entirely in the classroom, anybody who is academically capable can get through these years regardless of a disability.
Clinical rotations take place during the third and fourth years of med school—by which point most students have well over $100,000 of debt. Unfortunately, this is when it sometimes becomes obvious that a mental or physical disability will prevent an otherwise qualified student from finishing med school. Not only is the student debt massive, but the student has wasted two to three years of his life with absolutely no degree to show for it—and it’s back to the career drawing board. In my mind, that is a horrible injustice to the student, regardless of the good intentions of the admissions committee.
If you are in the position of being academically competitive for admissions to medical school, but you have some mental or physical disability that you worry may make it difficult for you to actually complete medical training, you need to honestly evaluate your disability. Talk to other physicians, close friends and family. Try to understand very well the myriad mental and physical challenges that await you once you start down the path of medical school, residency, and beyond. Be honest with yourself and decide if you think you can succeed. Don’t assume that a medical school admission committee has assessed this correctly just because you’ve been accepted.
Once you start down the path of med school, your student debt and time commitment is accumulating. If you are a good student and test taker, you will almost surely pass the first two years of med school. You don’t want to make it that far only to find out during your third or fourth year—or even worse during residency—that you just can’t overcome your limitations. The reality is that completing med school requires that you have the mental, physical, emotional, and communication abilities to succeed in a wide gamut of challenges, including the pre-clinical years of endless exams, as well as clinical rotations in internal medicine, general surgery, obstetrics, pediatrics, and family practice.