A Snapshot of Current US Medical School Off-Ramp Programs—a Way to Leave Medical School with Another Degree

Abstract

Although most students finish medical school, those who do not frequently have no obvious programmatic alternatives. In recent years, a growing number of medical schools have been developing “off-ramp” programs to help such learners. We surveyed 12 medical schools with off-ramp programs to understand their characteristics and challenges. Differences existed between programs but most were deemed helpful to the students and institutions they served. Advantages included the opportunity to acknowledge the students’ hard work, increase career opportunities, and reduce debt. Understanding and promoting such programs will assist students for whom medical school does not represent the optimal career path.

Background

Approximately 97% of learners who matriculate into US schools of medicine will eventually complete their medical school education [1, 2]. However, a small but significant percentage of learners will persist in the curriculum and finish their education without possessing knowledge, skills, attitude, or inclination to become a competent physician. Some of these trainees will encounter significant academic challenges such as failing grades resulting in dismissal from medical school or failure to successfully obtain a post-graduate residency. Others will belatedly recognize a dissipation of their desire to practice medicine, culminating in a demoralizing exit. The “failure to fail” an underperforming trainee is a well-known phenomenon described in the literature and contributes to some students remaining too long in the curriculum [3, 4]. Medical school expenses for these trainees represent an additional burden, with a median medical school debt reported in 2019 of $200,000 [5].

In light of these challenges, educators in recent years have increasingly recognized the need for compassionate off-ramps, described as “options to leave medical training without compromising ones’ self-esteem or incurring unmanageable debt” [6, 7]. Indeed, Bellini and her colleagues describe off-ramps as a “moral imperative,” arguing that medical educators have an ethical obligation to provide points along the educational continuum at which students can reflect on their goals, educators can effectively measure competence and identify struggling students sooner, and students can have the option to leave training [7].

As educators increasingly recognize the potential value of off-ramps, some schools have been quietly developing such programs. While the value of these products is unproven, they potentially have many advantages. As Aagaard and Moscoso point out, a certificate or master’s degree provides evidence of advanced knowledge, commitment to completing a medical sciences program, and a potential alternative career path [6].

This study sought to better understand the current prevalence and nature of existing off-ramp programs and to ascertain the inhibitors and enablers of developing such a program.

Activity

Our project was deemed exempt by the institutional review board at the University of Illinois at Chicago College of Medicine. First, we compiled a list of schools with off-ramp programs by conducting an online search, posting a query at the US medical school educators’ listserv (DR-ED@list.msu.edu), and networking with colleagues about known off-ramp programs. A total of 12 programs were identified and agreed to participate in our study (see Table 1). A questionnaire was created that could be administered via telephone. Individuals associated with these programs were contacted to solicit participation and arrange a phone interview. A project team member (JW) conducted the interviews, each approximately 30 min in length, between July and October 2019. Interviews were recorded with the permission of interviewees and detailed notes were taken. The results of the questionnaire were compiled and a content analysis was performed on open-ended responses, with interview content analyzed by project team members individually and then in teams of two to reach consensus on and summarize major themes. These summaries were then reviewed by all members of the project team to identify, clarify, and reach consensus on our findings.

Table 1.

Participating institutions

Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Georgetown University School of Medicine

Keck School of Medicine of University of Southern California

Lewis Katz School of Medicine at Temple University

Medical University of South Carolina

Michigan State University College of Human Medicine

Midwestern University - Downers Grove Campus

University of California Irvine School of Medicine

University of Colorado School of Medicine

University of Michigan Medicine

University of Utah School of Medicine

Wayne State University School of Medicine

Academic Institutions contributed to the survey July 2019–Oct. 2019

Results and Discussion

Off-Ramp Requirements

Degree requirements for the off-ramp programs varied considerably among respondents. Slightly less than half the programs (five of 12; 42%) awarded degrees with no requirements other than completion of medical school foundational science courses. Two (17%) schools awarded a degree to students completing 1 year of medical school and three (25%) schools awarded the degree with completion of 2 years. Seven (58%) off-ramp programs required completion of additional components beyond year 1 or year 2 coursework. Three (25%) programs mandated a “capstone program,” one (8%) required a three-credit essay course, one (8%) required successful completion of a “scholarly thesis project,” and two (17%) mandated passage of a comprehensive exam. Degrees awarded were relatively consistent, with most programs awarding a Master of Science in Medical Science or similar title. Almost uniformly, students awarded these degrees were not allowed to reenroll in the medical degree program. Only one (8%) of the 12 programs made reenrollment available to students.

Student Participation and Promotion of Off-Ramps

Programs were typically quite small, with none graduating more than five students per year. When offered the opportunity to participate in an off-ramp program, most students accepted. Schools varied in the degree to which they provided information about and promoted their off-ramp programs. Nine of 12 (75%) programs did not widely promote their master’s degree program; the other three provided program information to their entire student body. Four (33%) programs restricted information about the off-ramp option to struggling students. Students were generally informed about the program by a dean of student or curricular affairs. A number of respondents recommended sharing off-ramp information once students are identified as struggling and/or unlikely to succeed in their current program. Respondents emphasized the importance of advising students carefully about such a program so as not to suggest that the College of Medicine is “trying to get rid of anybody” or send the message “you don’t belong.” Concern was expressed to avoid introducing the off-ramp option too early, so as not to discourage students who might be able to overcome surmountable challenges and successfully become a physician. Respondents also expressed concern about promoting off-ramp options because of possible embarrassment to the school (i.e., that their medical school erred in selecting the best applicants). A number of respondents emphasized to students that their program was not a M.S./M.D. degree.

Off-Ramp Advantages and Challenges

Our respondents generally conveyed the belief that their programs were helpful to both their institutions and students, and they felt more medical schools should incorporate off-ramp programs. In addition, they were consistent in their reasoning regarding the advantages of off-ramp programs. Advantages included the opportunity to acknowledge the students’ hard work, increase their career opportunities, and reduce their debt. Respondents believed the off-ramp degree might enable students to find career options in teaching, healthcare consulting, medical administration, and pharmaceuticals. None of the programs was able to provide data to clarify whether or not these potential career opportunities materialized.

A challenge frequently cited of off-ramp programs was the effort to initiate the program, including getting the program approved and established. When queried about aspects of their program they might want to change, five respondents (42%) indicated no desired changes, while the others expressed an interest in adopting components found in other programs we interviewed, such as requiring a “capstone” project.

Our attempts to understand the prevalence, advantages, and shortcomings of off-ramp programs was hindered by a lack of attention to these opportunities in the literature. Our respondents also expressed a lack of awareness of any literature about off-ramp programs prior to establishing their own. Our study is limited by its small sample size. The individuals who agreed to be interviewed may represent a biased sample with an overrepresentation of positive experiences. Additional schools may also have such programs but be reluctant to share embarrassing or negative experiences. We hope this study may ameliorate the stigma of speaking openly about such a program and encourage our colleagues who provide such programs to increasingly share.

Our findings support the desirability of increased awareness of and research into the best practices of off-ramp programs. Particularly important would be a follow-up of off-ramp graduates to ascertain the potential long-term benefits. This study aids in understanding the concept and value of off-ramp programs. The true value of the degree and the potential opportunities it may provide remain unanswered and raise important questions.

Author’s Contributions

Richard Stringham, Jodi Whitlock, Norma A. Perez, Nicole J. Borges, Ruth E. Levine

Data Availability

Data and results are available upon request.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Code availability

NA