In a recent essay, I marveled at the qualities that will set apart tomorrow’s physicians from previous generations. And while everything I wrote I believed to be true, I suppose I neglected a major concern, a big blind spot as it were. In order to become clinicians, medical students must first enter practice. That seems obvious, but a recent report gives reason to pause and reflect on medical students’ experiences and career trajectories.

The report, Clinician of the Future: 2023 Edition, was released by the health science and journal publisher Elsevier in October 2023. In all, 2,212 medical and nursing students from 91 countries were surveyed between April and May 2023. Findings also included two roundtable sessions with stakeholders and faculty in the U.S. and the U.K.

A quarter of aspiring physicians in the U.S. – double the percentage in the rest of the world – said they were considering quitting their studies, with many expressing concerns about their mental health and how they can find a satisfying balance between the demands of school and life.

Among the U.S. surveyed medical students, 54% said they were concerned about their mental health, 57% expressed concerns about experiencing burnout, and 65% were worried about how clinician shortages would affect them. An unrelated 2023 survey showed that medical students have higher rates of burnout than physicians and residents.

The most striking statistic, however, was that 54% of medical students globally – 61% in the U.S. – said they viewed their current studies as a stepping stone to broader careers in health care that don’t involve treating patients. The main career paths students were interested in were public health management, research, and business consulting. The high percentage of students considering their studies as stepping stones to administrative and support roles was surprising, as those sorts of decisions are typically seen later in medical careers.

The question in my mind is whether the pressures of medical school are pushing students to rethink their careers, or whether there is something about these students or their education that makes nonclinical careers attractive to them? Of course, both a “push” and a “pull” could simultaneously exist, but the study did not specifically address this question. It seems to me that students who are genuinely interested in alternatives to practicing medicine will find greater fulfillment compared with those who simply want to escape the stress of future practice.

Sylvie Stacey, MD, MPH, author of 50 Nonclinical Careers for Physicians, writes, “I realized early in medical school that a conventional career in medicine wasn’t right for me. I eliminated medical specialties as career options as fast as I rotated through them … Nonclinical work has continued to be satisfying and challenging since I completed medical training.”

Sanjana Vig, a dual-degreed (MD/MBA) anesthesiologist, writes: “I made the decision to get an MD/MBA when I was still in high school. I had an interest in medicine but hated the idea of being yet another Indian doctor. How unoriginal. So, when my dad introduced me to someone who had done this dual degree, it was my “aha!” moment.”

MD/MBA programs have become very popular; approximately 70 medical schools in the U.S. offer the combined degree. MD/MPH programs have also become gateways to alternative careers. Timing is important. Although an extra degree can be earned in medical school, a more common pathway is to return to graduate school sometime after residency – for example, through an executive MBA program. Completion of residency and board certification are viewed as critical credentials for physicians even if they choose not to practice, so many doctors prefer to not interrupt their medical training until after they pass their professional boards.

According to Stacey, the primary career sectors available to physicians outside of practice are:

• Health care services delivery
• Health care finance and management
• Pharmaceuticals, medical devices, and biotechnology
• Technology and innovation
• Professional and financial services
• Writing and communications
• Public health and government
• Education and research
• Nonprofit sector (e.g., advocacy groups, professional organizations, certification and accreditation)
• Consumer health
• Consulting and entrepreneurship

Stacey’s website is a treasure trove of information for medical professionals interested in exploring nonclinical opportunities. She has a vibrant blog and online community named Look for Zebras. It’s an inside joke. In medical school, students are told not to look for zebras when they hear hoofbeats, meaning common conditions occur commonly, and those are the ones that should be considered first. Looking for Zebras is the equivalent of diagnosing a rare disorder instead of a heart attack when a patient presents acutely with crushing chest pain.

Stacey remarks on her website: “As a physician or other medical professional, there are tons of jobs out there that will leave you burned out and unfulfilled. These are horses. Zebras in your career are the rare opportunities that are truly a great fit for your interests, your personality, and your career objectives. Zebras seldom fall into your lap. You need to look for zebras.”

Another expression that has a connotation similar to zebras is “red herring,” as in: “it’s a red herring,” meaning the medical clue or information you are acting on is, or is intended to be, misleading or distracting. Don’t go down that rabbit hole!

I must admit I was one of those medical students who looked for zebras early in my career. No field of medicine other than psychiatry held my interest. One day, in my senior year of medical school, while on an internal medicine rotation, I snuck off to the hospital library. The most recent edition of The New England Journal of Medicine lay before me. I picked it up and scanned the articles. My attention was drawn to the clinicopathological conference, a discussion about a patient with eosinophilic fasciitis (talk about zebras!). Fascinating, but not relevant to psychiatry. I read it anyway.

The next day, students and residents gathered in a conference room to hear a lecture by a senior attending. He began to pimp us. Sure enough, he was describing the symptoms of the patient I had just read about in the journal. “What is this patient’s diagnosis,” the attending demanded, peering over his half-rimmed glasses, staring down the students and residents. I waited a few seconds. No one responded, so I blurted out, “eosinophilic fasciitis.”

You could literally hear my classmates and residents’ jaws drop. The correct answer had come from a future psychiatrist of all people, someone who was already beginning to be ignored by his peers and deemed non-mainstream, not having the “right stuff.” The attending was likewise astonished, chiding the residents rather than complimenting me for having the answer.

Despite Elsevier’s survey, I’m not convinced that a high percentage of medical students will actually forsake practice. The pressures facing current students have not gone unnoticed by medical school educators, who are attempting to remedy the many problems students must overcome in medical school.

In addition, students’ enthusiasm about technology and the use of artificial intelligence in education, plus their genuine passion to heal – 89% of medical and nursing students worldwide reported they were still devoted to improving patients’ lives – will propel most of them into practice. The survey findings give all of us working in health care much to consider as we strive to give today’s medical students the best chance to succeed in their medical careers.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.