The audition elective

Most academic radiation therapy departments offer rotations to “visiting” medical students. Visiting students generally have one of four basic motivations: (1) Some of these visiting students are motivated by a sincere desire to learn more about radiotherapy. Since radiation oncology is not available as a clinical elective in 7% of United States medical schools, these students are forced to look beyond their school for a course in radiation therapy.4 (2) A few students are undecided about a career in radiotherapy after a first course and hope to find career direction in a supplemental rotation taken at a different school. (3) Other medical students seek to combine an educational experience with a visit to a new city or with a chance to spend time with friends. To this end, they become visiting medical students as a pretext for a social visit. (4) Many visiting medical students have already taken one or two prior rotations in radiotherapy. They seek to take yet another rotation to impress the faculty of their new host institution with their fine qualities. To this end, they hope to achieve an advantage over the competition for residency positions. An official of the Association of American Medical Colleges (AAMC) has recently dubed this practice the audition elective.* An AAMC medical student graduation survey found that 44% of all 1986 medical school graduates had been advised to take audition electives to increase their chance of residency selection. The range per choice of specialty was large: 16% for pathology, 85% for orthopedic and neurological surgery, and 34% for diagnostic radiology.2 (Swanson, A. G., personal communication, 1987) From my discussions with colleagues, I can confirm that the practice of audition electives is often encouraged. Several advantages are touted. The visiting student is able to obtain a detailed evaluation of the potential residency position. He/she can have a careful look at members of the faculty as well as long conversations with current residents. The faculty, in turn, can closely examine the medical student and discern whether or not he/she is a desirable residency candidate. The audition elective may be particularly helpful to faculty members frustrated by the evasive letters of recommendation and nebulous transcripts too frequently provided in residency applications. It is clear that medical students seeking a residency in therapeutic radiology are under considerable pressure to succeed. In the 1987 AAMC graduation questionnaire, 83% of students pursuing a career in radiotherapy felt that “pursuit of a residency position” was either the “primary” or “major” influence on the organization of their clinical education. The average 1987 medical student seeking a radiotherapy residency spent $1,259.88 and 16 days in the interview process. In 1987 the mean indebtedness from pre-medical and medical education expenses for 80% of fourth year medical students applying in radiotherapy who are indebted was $34,473-compared to $29,289 for the general population of medical students.’ Faced with high interview expenses and large tuition debts, it is not surprising that some students will seek any advantage in an attempt to achieve a desirable residency. The results of the 1987 AAMC graduation questionnaire indicate that 12% of radiotherapy candidates applied to 1 or 2 residency programs, 53% applied to 3 to 10 programs, 18% to 11 to 15 programs, and approximately 16% to more than 15! Students were asked, “How many programs to which you applied suggested that you were more likely to be seriously considered for selection if you took an elective in that specialty at their institution?’ Fifty-three percent of the future radiotherapists reported no such pressure. Twenty-one percent of the students, however, indicated that one or two programs had suggested audition electives. Another 2 1% reported that three to ten programs had made such a suggestion. Approximately 36% of fourth-year students seeking radiotherapy positions took one to three electives at outside institutions.’ It is likely that a significant proportion were audition electives. There are significant objections to the practice of audition electives in radiotherapy. Audition electives are inimical to the process of medical education. The classic