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This is No Lake Wobegon: When Medical School Means You’re No Longer Above Average

 “Lake Wobegon, where all the women are strong, all the men are good looking, and all the children are above average.” 
– Garrison Keillor, A Prairie Home Companion

While NPR’s Garrison Keillor entertains listeners with weekly monologues highlighting news from Lake Wobegon, his fictional home town, it is that closing line “and all the children are above average” that has taken hold in the popular culture. The Lake Wobegon Effect refers to that normal human tendency to overestimate one’s abilities.

The problem is that an average is just that, an average, meaning that while some are above, there are also those below. We all want to be above average. Who shoots for the mean and makes it into medical school? The truth is, if you made it into medical school – or even if you’re somewhere earlier along the path – you have almost certainly been “above average” academically and otherwise most of your life. You were on the honor roll from the time you started receiving grades. You graduated near or at the top of your high school class, many being valedictorians. You were in your college’s honor society and graduated some version of cum laude. You were accepted to medical school.

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Average just isn’t in your vocabulary.

And then medical school happens. . .Now, having excelled all of our lives, we suddenly can’t all be above average. When I started medical school, I didn’t realize this was an issue. My first course was heavy on basic science; having just completed a master’s in molecular biology, the material was familiar. I studied hard and was reassuringly beating the mean, my nose bent slightly out of joint only for not receiving the top score. Then, in January, we started anatomy and physiology, topics that were new to me. I continued to study hard and thought I was ready for our first exam. Thus, when the results were back, I was crushed to find myself well below the mean.

I was frustrated with myself and felt that, on some level, I had failed. I had certainly failed to live up to my own expectations and realized how much of my own identity was wrapped up in simply being really good at school. It was then that I started to appreciate we can’t all be above average; some of us are going to fall to the left of that medical school bell curve despite our best efforts.

While there is a long tradition of competition in medical school as we all push to be at the top of the class, recent shifts have sought to promote collaboration and decrease intercollegiate antagonism. Publicly posted lists of test results and final grades are mostly things of the past. Many schools have dropped tiered grading systems for the pre-clinical years, replacing them with pass/fail grading1,2. My own school has recently dropped the honors/pass/fail system that prevailed when I did my preclinical training.

Although studies suggest that the pass/fail system improves our overall well-being and doesn’t decrease our academic performance2, it can’t entirely eliminate the feeling of competition amongst students, particularly as we hit our clinical years and grades once again come into play. Although it is somewhat reassuring to remember the old formula P=MD, the reality is that residencies are becoming increasingly competitive regardless of specialty as the number of residency slots fails to keep pace with the growing number of graduating medical students. Thus, it is important to distinguish yourself as a student, to show that you are more than average. This is particularly true for those headed to a more competitive residency.

What’s an ever-ambitious medical student to do?

There are (at least) two components to this answer: the personal and the professional. One is how you deal with your own personal qualms about where you are on that medical school bell curve. For this, I both did whatever I could to improve my test scores – went and saw the school’s education specialist who provided study suggestions, changed my own study strategies including joining a study group – and recognized that I was more than my test scores – taking time to nourish some of my non-medical interests, like walking dogs at the local animal shelter.

Take a moment to recognize that it can be startling to find yourself below the mean after being “above average” for the decade plus of education prior to medical school. Appreciate that you have far more to offer than your test scores.

The other part of answering the question is how you deal with this professionally in terms of residency applications. Although there are components of your residency application that may be harder to control, like your grades and USMLE scores, you can significantly improve other components of your application, particularly in terms of relevant extracurricular activities and letters of reference.

While scoring below the mean may make you feel like you should simply pour more time into studying, putting some of your energy towards other aspects of your resume can pay off in the long run. This could include a research project in your area of interest or being involved in your medical school’s free clinic or other volunteer activity. In addition to being a valuable experience and providing a line on your CV, these are also opportunities to establish relationships that can lead to excellent letters of reference which can be critical for scoring coveted residency interviews. Thus, regardless of where you rank in your class, you can take steps to strengthen your residency application.

For better or worse, medical school is not Lake Wobegon. For those of us who have been above average all of our lives, this can be a startling and uncomfortable reality. Fortunately, by taking a broader perspective you can both learn to live with this and strengthen your residency application.

Medical school, where the men and women must be strong, and all graduating students… will be doctors.

References

1. White CB, Fantone JC. Pass-fail grading: laying the foundation for self-regulated learning. Advances in health sciences education : theory and practice. Oct 2010;15(4):469-477.

2. Spring L, Robillard D, Gehlbach L, Simas TA. Impact of pass/fail grading on medical students’ well-being and academic outcomes. Medical education. Sep 2011;45(9):867-877.

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M
Megan Riddle, MD PhD, is a psychiatry resident at the University of Washington. She is a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program. Megan Riddle, MD PhD, is a psychiatry resident at the University of Washington. She is a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri...