Would-be physicians are often told that a winning medical school application requires stories about observing clinical care. Applicants’ quests to get clinical experiences — through, for example, physician shadowing, global health experiences or medical scribe work — can have harmful unintended consequences.
Such activities can perpetuate inequality when they disguise privilege as merit, reinforce damaging narratives or even hurt patients in poorer countries, and contribute to exploiting a vulnerable labour force.
We are medical anthropologists who have researched social and cultural dimensions of medical education. As teachers, we have worked with thousands of undergraduate pre-meds. We recently published, together with two co-authors, an article that we believe is the first to draw attention to how medical-school applications can cause broader harms.
Aspiring physicians encounter many sources of advice, from the admissions websites of medical schools to pre-health advising centres to paid coaches. All of these advisors recommend experiences that put medical-school applicants adjacent to medical care.
The advice may seem sensible. Watching medical professionals at work could serve as an occupational test drive. Applicants might better understand the profession before starting a long and gruelling training period — and possibly taking on a heavy burden of student debt. Admissions committees may also hope that such activities can provide evidence of personal qualities desirable in a physician, such as determination, altruism and a commitment to service.
It’s hard to say whether such experiences actually make for better doctors; the evidence is limited. The quest for such experiences does have other effects, however — and as anthropologists, those interest us. In particular, we want to shine a bright light on the effects that these activities have, in the broader social world:
- How do applicants’ social backgrounds affect their access to clinical observation experiences?
- Which potentially great doctors get lost along the way, discouraged even from applying?
- And how might pre-med students’ presence as observers matter, for practising clinicians and their patients?
Three common pathways to gaining clinical observation experiences are physician shadowing, global health experiences and medical scribe work. Each offers opportunities to get close to the practice of medicine, but each also brings unintended consequences that run counter to the values of the medical profession.
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Physician shadowing involves following doctors during their day-to-day working routines.
What a student is invited to observe varies considerably, depending upon policies around patient privacy and the idiosyncrasies of individual physicians. What patients are told about this “member of the team” may vary too.
The ethics of shadowing can be troubling, and the implications for equity are problematic. Though strongly recommended or even required by medical schools, shadowing is increasingly difficult to arrange without family or social connections to physicians. Studies show that students from less privileged backgrounds struggle to find shadowing opportunities and may become discouraged and give up.
Shadowing launders social privilege into individual merit, preserving medicine as a field for elites that masquerades as a meritocracy.
Global health experiences
Global health experiences are short-term volunteer stints in low-income countries. These opportunities have expanded dramatically in the last two decades.
Some are university led, others are run by for-profit groups and packaged as (expensive) tours. They bring students from wealthier countries to communities in poorer parts of the world to observe health problems and medical care, often across stark racialized divides. Without historical context for the differences they encounter, students can easily fall into regarding poverty and illness as somehow natural or inevitable, rather than recognizing them as outcomes of colonial relations and their contemporary legacies.
Placement organizations often market these experiences as helpful for strengthening one’s medical school application. Some of our own students feel caught between a distaste for what they call “poverty porn,” and the worry that such experiences are critical. For some, the cost is also prohibitive. We see additional reasons for concern: undergraduate global health tours can also reinforce colonial or “white saviour” narratives, slotting students and those they encounter into rescuer and victim roles.
When inexperienced students actually participate in delivering treatment, such as extracting teeth or delivering babies, they can also cause medical harm.
Medical scribe work involves clerical labour created by the adoption of electronic health records.
A scribe is present in the clinic, typing notes into a computerized record in real time while a physician speaks with or examines patients. The work is not well paid, and offers few opportunities for advancement, but companies that employ scribes advertise it as “the ultimate clinical experience that you can get before medical school.”
And, indeed, young people with excellent college training in biology or other science fields compete fiercely for these otherwise unpromising jobs, in hopes that they will strengthen applications to medical school, although there is little evidence that they do.
Much as the slim hope of playing in the NFL helps fill the ranks of student-athletes on U.S. college football teams, the slim hope of gaining admittance to medical school helps staff low-ranking clerical positions within medicine. In this way, the competition for medical school admissions may contribute to exploitative labour conditions.
All three of these pathways to clinical experience worsen the inequalities that trouble medicine as a profession. None of them has been demonstrated to make better doctors. Some of them cause harms far afield. All of them are likely to put excellent applicants from less privileged backgrounds at a disadvantage.
It is time to apply “first, do no harm” to the medical-school application process.
The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.