A Dean’s Perspective on What Makes Great Physicians

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Words of advice for premeds and medical school applicants [Show summary]

Dr. Sunny Nakae discusses CUSM’s approach to training the next generation of great physicians and shares wisdom from her book, Premed Prep: Advice from a Medical School Admissions Dean.

Are you curious about CUSM? Read on for info about this new program and for valuable tips for all medical school applicants [Show notes]

How do you prepare to become a physician? How do you prepare to apply to medical school? Our guest has written the book on the topic, after two decades in medical school admissions.

Today’s guest, Dr. Sunny Nakae, is the Senior Associate Dean for Equity, Inclusion, Diversity, and Community Partnerships at the California University of Science and Medicine School of Medicine, one of the country’s newer medical schools. Dr. Nakae earned her bachelor’s and MSW from the University of Utah, and then her PhD in higher ed at Loyola University of Chicago. She started working in medical school admissions in 2006 as Director of Diversity at Northwestern’s Feinberg School of Medicine, moved to Loyola Stritch for six years as Assistant Dean for Admissions, Recruitment, and Student Life, and then another two years at UC Riverside, again as Associate Dean, and then last year joined CUSM as Senior Associate Dean for Equity, Inclusion, Diversity, and Community Partnerships. All that experience is reason enough to invite her to Admissions Straight Talk. However, I also want to discuss her fantastic book, Premed Prep: Advice from a Medical School Admissions Dean.

Can you give us an overview of the CUSM MD program, focusing on its more distinctive elements? [2:18]

California University of Science and Medicine School of Medicine is a community-based medical school. That means that we are really focused on training in a lot of different sites. We’re focused on primary care. Our main affiliation is Arrowhead Regional, but we also have sites at St. Bernadine’s and other places. We’re in inland Southern California, so about 90 minutes/a little under two hours from the coast. It’s a very underserved and economically divested region of California, so our goal is to produce more physicians that want to train in our region, and stay in our region, and take care of the people that live here. We have early clinical experiences, where students are placed with preceptors and clinics, outpatient settings, so they get very comfortable with outpatient and preventative care and ongoing clinical home settings.

Another distinctive element that we’re developing is we’ve recently changed our service learning into something called Change. Students will have a similar placement with a community partner that they do on the clinical side through the Care program. Care and Change together are going to create this opportunity for students to actually learn about structural determinants of health, and what our director calls health adjacent services. It’s a way for us to give back as a school, which is important for us. We want to make a departure from the typical pedagogical models that use a colonialist approach of, “We’re going to come in and do what we want on our terms, and demand certain things of you, and impose our learning objectives on you, and then go away. And then a new group of students is going to come in and do the same thing.”

The students are going to be put into college groups and be assigned to a community partner. Let’s pretend it’s Harm Reduction in southern California. They’re going to work with this community partner or nonprofit organization or educational group. The student’s job is to learn about what the community partner’s goals are, what their strengths are, how they can actually leverage the talents and gifts they bring to the school as students to actually help our partners achieve their goals. The learning is real learning, the contributions are real contributions, and we’re really helping. That’s why we call it Change, right? It’s not a service project; it’s a contribution to Change that is co-directed and led by our community partners.

We’re hoping to have those folks come and lecture to our students, presenting their expertise, these community partners as experts who can really teach future physicians how to navigate aspects of the community that can be really challenging, like housing insecurity, food insecurity, employment, immigration challenges, mistreatment, abuse, policing conduct, all that kind of stuff. I’m excited about it, because I know students crave very much to make a difference, and go into medicine because they care deeply about community, and then they’re totally disconnected from community; it’s extracurricular in medical school. We want to give back through our educational process by leveraging the strengths that our students have and the passion that they have as part of the curriculum. Everyone will do it, and they’ll do it in teams in their college groups, and hopefully also be part of a leadership structure that will help us continue to maintain continuity through our community partners, lessening the burden on our community partners for onboarding us and teaching us how to be in their spaces.

So Care is more about clinical exposure, and Change is more about nonclinical community service. Is that a fair characterization? [5:56]

Yes. Some of the Change sites might, like Harm Reduction for example, have clinical elements to them. People exchange things, but they’re not providing medical care. So yes, all the Care sites are primary care sites, and then the Change sites are health-adjacent and could be any number of things that contribute to structural determinants of health.

Are the students still having this exposure, whether it’s through Change or Care, despite COVID? How has COVID affected the non-didactic portions of the curriculum at CUSM? [6:30]

We’ve had to change a little bit for this year. I joined CUSM in October of 2020, so the faculty had already done a lot of adaptations due to COVID. We’re prospectively revamping our service learning, because a lot of it ended up being virtual. We gave students anti-racism, anti-oppression reading lists, asked if they wanted to do book clubs, and they’ve done programs. Some of our students have helped with vaccine rollouts and vaccine education, trying to do outreach to think about improving community capacity to get people the care that they need. We’ve had students share those projects as part of it, as much as our post-COVID and post-vaccination world is allowing. But a lot of stuff was done more virtually this year than what we really would’ve preferred. The clinical skills we ended up doing in small groups, because it’s pretty hard to teach those remotely. But we’re hoping to get back out there, and I know the students are quite eager to continue their clinical outreach, and street medicine, and other aspects that they do in our county.

Let’s turn to the application for CUSM. Are your secondaries screened in any way before they’re sent out, or are they automatically sent out? [7:48]

I don’t think our secondaries are screened, and I was trying to look at the answer to this. We send them to verified applicants, because we get so many applications. We got 2,000 or so. We just recruited our fourth class, so the class of 2025 is our fourth class. We’re now at a full complement. We graduate our first class next year. We went from getting a couple thousand applications to this year, where we’re well over 6,000 applications.

What do you hope to learn from the secondary that you don’t learn in the primary? [8:27]

One of the things that we are adding for the coming year as part of my role in equity, inclusion and diversity is synchronizing and implementing equity practice across faculty, staff, and student areas. We have some equity practice and anti-racism questions that will be on our applications to join as staff that are in our faculty search processes and that are also going to be on our secondary. We’re interested in a person’s previous experience and/or openness or willingness to learn about life experiences, identities, and challenges that have been different from their own. We want to assess a person’s openness and willingness to engage in that learning, because we have a goal to be and to continually strive to be an anti-racist institution, and that requires universal engagement in equity practice. Hopefully students will take the opportunity to share with us in those questions that will be added to our supplemental for the coming admissions cycle. Our master’s in biomedical sciences program, which is like our postbac program, also has the questions. The rubric is the same across all of those constituencies, because I think in a professional school, everyone can be held accountable and sort of respond to how they are doing these things, and how they think about this in their professional journey.

How would you address concerns that CUSM is a new program and so far has only preliminary LCME accreditation? [9:52]

There are different phases of accreditation for the Liaison Committee for Medical Education, the LCME. You apply and say, “Hey, we’re thinking about becoming a school,” and they say, “Okay, we’re going to allow you to submit an application,” or not. And then you submit your application to become a school, and you get provisional accreditation, which means, “Okay, we’re going to let you submit the full docket of things, and you’re not actually allowed to recruit or do anything.” You’re allowed to tell everyone, “Hey we’re starting a school,” but you can’t do anything else. So once you actually pass your provisional accreditation, you get preliminary accreditation, which is what we have. The LCME comes back much more frequently in your early phases of developing a school to check on your policies, but there’s a lot of aspects that they can’t do a final review on until you have a graduating class, right? How did you do, what are you training, etc.

We have these continual processes, and I feel like we meet every week. We have a Dean of Compliance and Accreditation, Dr. Seki. He’s amazing and galvanizes all of us around this planning. So we are accredited; we’re allowed to recruit, graduate, train students. Even if something went wrong with our accreditation, students who are at the school will be considered graduates, and then moving forward we wouldn’t be allowed to admit more students.

I’ve been part of several site visits for LCME. I have either good luck or bad luck, I guess: When I was in Utah, we did an accreditation visit. I was at Northwestern for eight years and caught the front end and the back end, literally walked into accreditation, and then had to do it again right before I left. And then Loyola actually did accreditation while I was there, and UCR’s in the middle of accreditation. I don’t know if it’s a blessing or a curse, but I keep landing in places where accreditation is on the table.

Having been part of our discussions now for the last six months, I’m confident in our ability to meet the requirements, and I think we’re doing an exceptional job, and really trying to innovate and do things differently. That’s what I love about CUSM. It’s why I chose to join: there’s such an openness to new ideas, and such an openness and willingness to improve. We’ve started a lot of equity practice and engagement around equity, inclusion, and diversity, and it’s been great to work with our community and have it be part of what we’re trying to shift and shape in inclusive culture.

Right now, in May, some people have accepted offers, and some people have outstanding offers. You’re presumably drawing from your waitlist. How do you view letters of intent or correspondence from waitlisted applicants? [12:40]

I would think positively. I’m not the admissions dean at CUSM, but I’ve been involved in admissions at a lot of schools, and I don’t think it ever hurts. I say this in my book. I don’t think it ever hurts to advocate for yourself, right? To professionally let people know where you are. We don’t know anything, so if we have silence, we might assume you’re really interested, or not. The longer the season goes past the drop date, April 30th, the more certain the admissions deans want to be that if they reach out to an applicant and make an offer, that that applicant will accept because we are always eager to fill our classes and to get our classes seated. Letting people know, “Hey, I’m still interested,” or, “I have another offer but you’re still my number one choice. I’m holding out,” it’s helpful. A small update about, “These were my grades from last semester,” or, “I’ve continued to work in such-and-such community organization,” or, “I’m working on a manuscript,” just small little snippets of what you’ve been doing is helpful, I think. It can’t hurt, unless you do as one of my applicants at Stritch did one year and literally sent an email every day. I finally had to help them recognize, “Okay, you might be thinking that this is you being really persistent, but actually we get hundreds of emails a day and this is outside of the bounds of professional behavior.” The applicant said, “Oh, I’m really sorry.” And I thought, “Good that we had this chat!”

I have, as you know, I have a chapter on professionalism in my book because I thought we need to be much more explicit about this. I love millennials, Gen Z, gen Y. I love working with students. You probably can tell from how I write about them. And I do think that we need to be more explicit, rather than this whole, “You should know better,” attitude. People’s learning modalities socially are really different than they used to be, right? We have to take that into consideration and get outside of our own heads sometimes. I wanted to present a little bit about how we see you when something like that happens. When you bring your mom to interview day, we sort of scratch our heads a little. These are just the sort of things that if we can’t add it up, we tend to go away from it, versus things that we understand or interpret, which we tend to be much more in favor of. That’s the nature of bias and how it all works, but I thought it would be helpful.

Originally, the title for the book was Behind the Admissions Office Door. I wanted to peel back that curtain and help applicants understand how their behaviors are interpreted and how they’re going to be viewed. Though with the mom coming to interview day, not every parent gets that professional context, you know? We didn’t know if they had driven together and there just wasn’t anywhere else for them to sit. They could’ve hung out in any number of waiting areas, away from right outside our door all day. One of my staff was like, “Maybe they’re in the witness protection program. It’s not really their mom.” My staff was like, “Do you want lunch?” At Loyola, we’re such a warm place and such a hospitable place, and it was just so odd. We just wondered, how’s this person going to do? For interview day for a professional program, it’s just really a strange practice.

COVID has affected lots of things in the admissions process, and one of the things I think it most affected was interviews. I think all medical schools are having virtual interviews this year. Next year, public health policies permitting, do you plan to go back to in person interviews, or do you plan to stick with the virtual ones? [16:27]

I don’t know what our committee’s going to do. There’s a lot that I like about online interviewing. I think it goes to show you that medical education is just so slow to change. There’s certain ideas that are sacrosanct, that we just cannot let go of. People so vehemently felt, “You need to get a feel for the person; you can’t do that over a virtual interview,” because there have been times when I’ve had people halfway across the world that just couldn’t make it to their interview day. There are also applicants who don’t apply to as many places or turn down interviews because they can’t afford to go, or aren’t able to go as early in the season as they should because they don’t have the money, right? There’s a lot of equity implications to how we do this, and almost every dean I ever talked to, and committee members too, said, “No, we want to lay eyes on this person. We want to be in their physical presence.”

Then COVID came, and everyone said, “Okay, we figured it out.” And then we were all forced to do it. All of a sudden, we said, “It’s actually not that bad, and there’s aspects of it that we like.” I don’t think we’re always going to be only selecting people this way, but there might be things we revisit, or there might be other modalities. I know a lot of deans are really concerned about offering both, because we feel like one or the other is a more fair application of how to do it. You might have a bias built in; “Well, this person was really invested so they showed up in person,” that kind of thing. But I hope a lot of schools do keep the virtual interviews, because I think while they introduce different kinds of bias, the socioeconomic burden of interviewing can be in the thousands for some applicants, depending on where they live and how they travel.

I’d like to turn to your book, Premed Prep: Advice from a Medical School Admissions Dean. Early in the book, you wrote, “My goal with this book is to shift the paradigm from, ‘What do I need to get into medical school,’ to, ‘What kind of person do I need to be in order to become a physician?'” Why is this shift necessary? [18:29]

That’s the crux of the book. When I work with students, there is such a worry about, “How am I going to stack up? How are my resume, and all these elements and experiences of certain types, going to be received?” There’s this element of competition that really undermines joy, but also authenticity. “Oh, well you’re doing Relay For Life? I guess I better do Relay For Life. Oh, you joined the Honor Society? I guess I better.” People feel this benchmarking of themselves with each other, when none of that really matters when you’re face to face with a patient in one of their most vulnerable moments. That’s about knowing who you are and why you wanted to be sitting there, why you wanted to be the surgeon at the helm, why you wanted to be the hospitalist who’s managing difficult cases, or a pediatrician counseling a parent and child. It’s really a journey of transformation.

The students that I witnessed that did it well, that were the best applicants, had at their core who they were and their reasons and purpose that really shone through. I started to notice that it wasn’t necessarily all of the accolades; it was what those accolades and the journey meant to the student. I had the benefit of working with students in the pipeline, but also working with them after they got to medical school, because I was either the Director of Diversity or the Student Life Dean. I got to watch how and whether students really thrived, and there were students who did the checklist and got in. They were less happy about their experience and their professional journey, more disillusioned at the end, more likely to say at the end, “Yeah, if I would’ve known all this, I wouldn’t have gone.” It’s almost like they got so caught up in whether they could get in and get that gold star that they sort of missed the fact that you’re signing up for a lifetime of vulnerability with patients, and yourself, and this growth process. I want to offer that reassurance too, that your life experiences and who you are as a person matters deeply to how successful you’re going to be as a physician. And when people hear that, I think they sort of relax a little bit, because they go, “Okay, well I didn’t have a thousand hours of this or that, but I’m clear about X, Y, Z values, or this purpose, or resolute in why I’m choosing this path for myself.”

You’re much more likely to find something at the end of that whole process that you’re happy with, right? If you still choose medicine, then maybe it’s what specialty you’re going into. It’s really about knowing yourself and your professional identity formation. We don’t talk about it as much, but it’s really at the core of wellbeing too. If you choose this career, it’s not all about the competition of just getting there. The satisfaction is really rooted in the purpose of why you’re there in the first place. I agree with all those residents and physicians who said to pay attention to the things that bring you joy and really pursue those things. There are ways to incorporate that into your application and not shove yourself inside the checklist box.

How would you address people who might have some low grades or a low MCAT score and think, “I’m an impostor. I don’t deserve to be a physician”? In other words, impostor syndrome. [22:39]

I think what makes impostor syndrome in medicine and science that much more difficult is that we all have it to a certain degree anyway. We have these moments where we’re like, “Who am I to be doing this?” Even I sometimes look at my book and go, “I wrote a book!” I never really thought that I would. Medicine and science, because of their roots, originate from very male, elite, dominant, white, cisgender, hetero norms and cultures. Those spaces are designed to tell you that you don’t belong. It actually is not designed with you in mind in the first place. Impostor syndrome in those places, it’s amped; it’s on steroids.

It’s normal, I would say, first of all, to feel like, “What am I doing here?” Every person who’s become a parent or taking on caregiving responsibilities for little humans asks themselves that all the time. “What am I even doing? What is happening here?” We all have those moments. It doesn’t mean that you’re going to be a bad caregiver because you’re questioning yourself. I think it’s healthy to have some sort of reflection, and to step back.

That humility sometimes goes over into taking away confidence. I saw that a lot with underrepresented students who’d experienced that. They had gone to really elite institutions, and I remember one interview I was in at Northwestern where the student came in and said, “I’m really excited to be here. I just want to apologize for my MCAT score.” I said, “Hold on. Your MCAT score is 85th percentile. Why are you apologizing for your score?” “Well, I know I’m below the average for the school.” And I said, “Okay, we’re going to pause the interview for a second. Stop doing that. You’re a great applicant. You wouldn’t be here if we didn’t think you were.”

Sometimes the things that we think matter and we’re so hung up on don’t matter to other people. I don’t know if you watch Schitt’s Creek, but my kids and I love the scene with David and Alexis, where Alexis is helping David step out of his anxiety of what everybody else thinks, because he’s so afraid he’s going to fail at this driving test. She says, “Nobody cares, David.” So we say that in our house a lot. I have middle school girls, and my son’s 15. “Well what if I do this, and such-and-such?” “Nobody cares, David.” You’re in your own head with all that stuff.

To get back to your question, for someone who doesn’t feel like they’ve had perfection, perfection is not the goal, right? We don’t want people in medicine who are perfect at the expense of progress. In order to have innovation, in order to have those breakthroughs, we have to be willing to fail. Sometimes the greatest character development and learnings come from when we fall short. I talk about character development in my letter to applicants that don’t get in, and I really wrote that very firmly, but also lovingly, to sort of help applicants understand that none of this is really guaranteed. Who you are at the end of the day is what you’re left with when you try for something. How do you behave when people aren’t watching? What sort of future do you hope and wish for for your friends? This is really what makes up who you are.

I always want to encourage those students. I’ve worked with students whose undergraduate GPAs were below 2.0 because they had repeated so many courses. One of those students is today a resident in urology. So if you want it, we can make a plan. For this physician, it was a five year plan. They came to me saying, “I’m going to apply to medical school.” And I looked at their stuff and I said, “Okay, well, not yet. You are, but not yet. Let’s figure out how to get some postbac coursework under your belt; we need to improve your MCAT score; we need to get some research experiences. You’re going to really have to overcome this record to get your foot in the door.” But it is possible, and I just love that I know students that have persevered.

Even in medical school, when students sometimes don’t pass their boards on the first attempt, they think, “Oh my gosh, this is the end. Everything’s crashing down.” Let me just connect you with 10 other people who didn’t pass their boards on the first attempt who are happy, practicing physicians today. There’s some perspective-taking that we can do for each other in those moments.

What’s your top advice for writing a personal statement on the primary application? [27:14]

Make it interesting to read. I spend a lot of time on personal statements, and the whole impetus for the book came from ranting about that. I put things in that people did as applicants or things I read about, “Don’t do this. And I never thought I’d be saying this, but don’t do this.” Like someone winking at me in an interview, which was the strangest thing. The person listed that they played like six instruments, and I asked, “Oh, talk to me about playing these instruments. How many instruments do you play?” They listed them all, then they said, “Oh, but seven if you count my voice.” This had never happened to me before. Maybe this person doesn’t realize what the social currency of winking is, and how weird and off-putting and inappropriate that was? Then I had to write a de-identified story on Facebook and got all these comments. So I pasted that in and redacted and changed some details of this stream of consciousness, terrible personal statement mess. One was about doing CPR on a goldfish. These can’t happen.

Alden Landry, who’s actually one of the co-founders of Tour for Diversity in Medicine with Dr. Kameron Matthews, said, “Put your money where your mouth is, Dean Nakae. What should people write about? You’re constantly criticizing applicants. Why don’t you tell us what they should do?” I said, “You know what Alden? I will.” So then I published that blog, Tough Love for Your Personal Statement from a Medical School Admissions Dean. It still gets the most hits. My former chair always says it still gets the most hits because somehow it really struck a nerve with people.

I talk about the use of reflection in personal statements. The meaning-making, the “so what” of your experiences that we want. If somebody else could change a couple details and put it on Reddit and it could be their personal statement, then it’s probably not done yet. And if you don’t have the depth of reflection about your experiences, then it’s time to reflect on that. Why don’t I? Why can’t I derive meaning or purpose? Why am I having a hard time articulating what this journey means to me? Then we need to go back and fill in some connective tissue in a growth zone and figure out, why do I want to do this? Because that’s a really important question to answer before you embark on $200,000 in loans and eight years of training.

Regarding activity descriptions, you wrote in your book, “It is the meaning-making and the personal gains from your experiences that truly create value, not the hours. The hours you catalog likely will not compensate for gaps in reflection and depth in both initial and subsequent phases of the admissions process.” How can they obtain meaningful clinical exposure today with COVID and the restrictions? [30:03]

That’s definitely a challenge, because most of our medical students for a good period of time got released from clinical sites, because of the dangers of COVID. Virtual shadowing can be helpful. Again, you do have to work to think about and reflect on what you’re seeing: the decision-making process, or the background, or how this provider interfaces with faculty, other colleagues, ancillary staff members in a healthcare setting. I got invited to be part of a student run organization, Pre-Health Shadowing, which I really love. The students that are working on the board are trying to make this sort of worldwide free resource. Again, this is why I love Gen Z and the iGeneration, because they saw a problem and figured out how to create this global organization to solve it in like a couple months. I got this invitation, and I was albeit admittedly skeptical about this. Then I went to the first meeting, and it was so well organized and so well thought out. They had access and equity and those types of things at the top of the list for why they wanted to exist in the first place, and it was a very soulful and purposeful group of students.

Reading books and listening to podcasts is a great way to expand your worldview and do some of that reflection. It is a form of vicarious learning, you’re not there in person, but you can listen to the stories, and that really does increase your bandwidth for understanding the role of a physician, and how healthcare goes together. There’s a lot of podcasts by current physicians that are really accessible. Several of my former students actually do them. Wendy Goodall McDonald does one called Dr. EveryWoman. She talks about women’s health and all sorts of stuff. She does fun parodies of pop songs to talk about women’s health issues. There’s one called Chocolate Medicine, which is four black women physicians, and they talk about different health topics. They’re trying to make these things much more accessible by integrating and bringing in unique aspects of Black culture into medicine. There’s a lot of listening and reading you can do.

There’s books about physician experiences. One that we had our students read years ago is called Attending Children. The author is Mormon, and it goes through the medical student, resident, and then attending physician experiences as a pediatrician. Not a beach read though. I was reading it because our students were going to read it, and we were on vacation in Florida and I’m sitting by the pool and bawling. My husband said, “This is vacation, what are you doing?” But there’s lots of great stuff. Atul Gawande writes great stuff.

You can do your own learning and be in charge of your own learning. It is possible to shadow and learn absolutely nothing and not really be present to the experience. What we hope you get from shadowing is understanding what you’re getting into, getting insight around doctor/patient relationships, the challenges that doctors face. You can get that through other mechanisms, even in the time of COVID, through other media forms. The pre-health shadowing that I’m now on the board of is virtual shadowing. They record all the sessions, they have them all on their website, and they try to encompass a broad scope of pre-health areas too, so it’s helpful.

Since in-person shadowing is very difficult if not impossible at the moment, do you feel that virtual shadowing is a good substitute and an acceptable form of clinical exposure? [34:08]

Yes. I’ve always worked with students who couldn’t access clinical exposure, because I work with a lot of first gen students and undocumented students. Sometimes those students don’t have the time. For a while, when some hospitals required social security cards and different types of onboarding processes for volunteers, I had undocumented students that weren’t able to get clinical exposure in that way. Hospital shadowing has become much more restricted because of risk management. When I first started in med ed 20 years ago, we’d just call up our docs and say, “Can we send some high school students your way for the day?” And it was fine. Now they have to get all the immunizations and do the same kind of medical clearances that our medical students have to do, and there’s expense to that, and a lot of red tape and delay for that, so it’s not as simple as it once was.

Again, I want to focus on the learning that shadowing is supposed to get. You can get exposure to health professions, to medicine, via these other means. Some people get it through taking care of someone in their own family, growing up with a person with a chronic illness, or a sibling that has a disability. Again, what kind of insights have you gained from those experiences? I think it’s helpful to be able to shadow and get in there, but plenty of people have gotten into medical school not doing that. Can they answer the questions around what a day in the life of a doctor is like? What are the current challenges facing physicians? Or why is physician wellness such a thing these days? Do you have insight into a profession that you’re essentially asking to join?

I would really defer to the purpose of those activities, rather than being there in person. A lot of people feel, “I have to be a scribe, and if I’m not a scribe then I’m never going to get in.” But there are students who have scribed that are not good candidates, right? Because they’re not paying attention, or again, they’re using a very checklist kind of mentality. “Well I’ve got my thousand hours, so I should be able to submit this, then Dean Nakae’s going to just push me right on through because I have all these hours.” It’s not that simple.

Most of our discussion has revolved around applicants applying this summer, or in the midst of the application process, to matriculate in 2022. What about applicants who are in the process but maybe planning to matriculate in 2023 or dreaming about becoming a doctor further into the future? What should they be doing, and how should they be becoming the kind of person who can be a great physician? [36:19]

I’ve been listening to a lot of Brené Brown lately. I love all things Brené Brown. I’m a super fan and nerd. But I really think it’s about growth and vulnerability, and I write about the growth zone in my book. The growth zone is a place where you might fail, where you are deeply uncomfortable, where you’re skilling up as Brené would say, in areas that maybe you didn’t know before. It’s honest self-appraisal. Some students will say, “I know I’m socially awkward.” They might be a first year undergrad or a second year undergrad. I’ll say, “Okay. What does the growth zone look like for someone who’s socially awkward? What can we do?” “Well, I started volunteering at an intake center for a temporary housing shelter, so I literally have to meet somebody new every 10 minutes, and I have to practice my skills, I have to shake their hand. They have very different life experiences than I do, and I’m able to make a contribution to this community organization. But slowly, I’m getting more comfortable with myself and I’m able to learn how people are taking my cues and really refine some of my interpersonal interactions and my body language.” Awesome, right?

Sometimes, we want to think about only putting forward our strengths, and not thinking about where our limitations are. For some students, it might be, “I need to become a better student. Not my grades, but actually how I study and how I learn.” Because some practice what we call the crash and burn. Some students, everything’s been easy for them. They’re perfect. And then they get into med school and it’s really hard, and they actually don’t know how to study. So then they end up in the Academic Center of Excellence, or academic support center, talking to our coaches who say, “Oh, well this is how you concept map. This is how you consolidate. This is interweaving.” What are those different types of learning modalities that you need to be good at to do a really hard graduate program?

I like for students to take a little bit of an inventory of what their strengths are and continue to focus on those, but also I ask, especially early on, what are your limitations? What are the areas that you haven’t explored yet that you really want an opportunity to explore and stay open to what speaks to you? Whether it’s a different health professions area, whether it’s something completely different. I’ve had students make really wonderful journeys into being health educators and nutritionists. If you do it right, then you are open to ending up somewhere different than what you thought at the very beginning. The rigidity does not often serve us well, or help us attend to and respond to where our strengths and gifts really are.

That includes our interpersonal learning around growing up differently. I worked with a lot of students in Utah who recognized that their upbringing was atypical in terms of being sheltered. They’d grown up in this place that really sort of wasn’t like the rest of the world, or even the United States. Their exploration included, “What kinds of things do I need to do to attend to that?” It’s kind of the “know better, do better” philosophy. I need to learn a little bit more about the world and myself, and continue to be a learning person, and focus on that improvement and responsiveness.

Premeds get pretty stuck in their plans and rigidity, especially around, “I’m going to apply in 2023, and I’m going to take the MCAT on this specific day.” And then they’re not ready to take the MCAT, and I go, “So now you’re coming to me six months later. You’re not happy with your MCAT score. What happened?” “Well I knew I wasn’t ready to take it, but I told myself I was going to take it in June, so I did it anyway.” And now we’re here, six months later. Wouldn’t it have been better to just do one thing at a time? To say, “Okay, my next focus is really improving my study skills and taking the MCAT. And once I think I’m ready to do that, then I’m going to start planning the next phase.” But people get so rigid into their timelines, and even into their goals, and forget the “why” of “Why am I even doing this in the first place?” I’ve talked to premed students who are straight up miserable. I ask, “Talk to me. Is this what you want to do?” Things come out like, “Well my parents have expectations,” or, “I’ve always told everyone this is what I want to do but now I’m not really sure,” or, “I’ve had some experiences where I’ve felt really defeated, and I’m having a hard time seeing myself in this career area anymore.” Having space to question and continue to revisit is really important.

It’s not about how fast you get there, right? It’s really about being happy with where you are. And the worst day of medical school is day two. The first day, you get your acceptance, and it’s amazing. This is a goal you’ve been striving for for so long. And then there’s this dread that sets in of, “Now I really have to do it. Now the work starts.” And it is a big letdown. You see a noticeable diminishing of enthusiasm in the class as the first semester gets underway, and people really realize, “I have a lot less free time.” There’s a bunch of realities that set in around, “Oh, but this is what I wanted.”

What I encourage my first years to think about is a psychological technique, the counter-factual. How might you not have ended up here, right? Which might make you appreciate the space where you are. Think about where you wanted to be two years ago, how bad you wanted to be in this seat, in this classroom, right now, doing anatomy, doing histology, grinding it out in pharmacology. This is really what you wanted. And then there’s the greater purpose of it, which is to be there for a patient, which is sometimes hard to remember when you’re in the grind of those basic science years in medical school.

Where can listeners learn more about CUSM? [44:01]

CUSM.org is our main website. Once we’ve received our accreditation from the Western Undergraduate Universities one, then we’ll get an .edu address. But because we’re a nonprofit medical school at the moment, we have a .org address, so that’s probably why it sounds a little funny at the moment. Then we’re also on Twitter, and you can find my book on Barnes & Noble, Amazon, or from Rutgers directly.

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