Unveiling the Gatekeeping in Medical Education: My Journey, Domestic Violence, and Systemic Failures

Hey there, resilient warriors! Today, I want to share a piece of my heart, my story, and how it intersects with an issue that affects countless others in the healthcare field: gatekeeping in medical education. But this isn’t just about stastics and academics—it’s about trauma, systemic failures, and resilience in the face of adversity. It’s about me, my experience with domestic violence, financial struggles, and fighting for my place in healthcare despite all odds. I want this to be more than just a blog post; I hope it opens a conversation about systemic inequities in both education and healthcare.

P.S. This is a converstaion starter and is a first look at my story from a very highlevel overview, far from all encompassing. There are specific details of certain extenuating circumstances I faced that need to be left out at this point in time for reasons that will become apparent when it is safe and appropriate to share.

The Struggle is Real

Our healthcare system is in desperate need of medical professionals. But ironically, many aspiring doctors, PAs, and nurse practitioners are being blocked by the very institutions that should be paving their way. The rigorous and often unfair barriers in medical schools, PA programs, and Nurse Practitioner (NP) programs are a significant part of the problem.

Medical schools rely heavily on standardized tests like the MCAT and Step exams. These tests, especially the Step 2 Clinical Knowledge exam, put immense pressure on students. They emphasize test-taking skills over essential qualities like empathy and integrity. No wonder the attrition rates are so high—between 15.7% and 18.4% for medical students alone! (AAMC, 2023) (Med School Insiders, 2023).

The PA Program Challenge

PA programs aren't any better. The average attrition rate hovers around 6-7%. For instance, the Canisius University PA program saw an attrition rate jump from 4% in 2021 to 13% in 2023. The University of Saint Francis reported a staggering 28% attrition rate for its 2023 cohort. These figures are alarming, given the high demand for PAs (Canisius University, 2023) (University of Saint Francis, 2023).

And then there's the Physician Assistant National Certifying Exam (PANCE), with a failure rate of around 5-7% annually. This high-stakes test adds to the stress and burnout among PA students (PAEA, 2022). 

The Mental Health Crisis

Mental health is a critical issue among medical, PA, and NP students. According to studies, about 27% of medical students experience depression, and 11% report having suicidal thoughts (Rotenstein et al., 2016). In PA programs, a survey found that 36% of students reported significant anxiety, and 25% experienced depression symptoms (Physician Assistant Education Association, 2019). Similarly, NP students also face high levels of stress, with one study showing that 43% of NP students reported high stress levels, impacting their overall well-being (Dreher, 2017).

My Personal Tale

Now, let’s talk about my story. I excelled in clinical settings but struggled with my PAEA exams (precursor to PANCE licensing exam). Despite my dedication, these challenges led to my dismissal from the UW-Madison PA program.

My journey was marred by personal challenges, including PTSD, ADHD, and significant family trauma. I sought therapy and used university resources like the McBurney Center but found the support lacking. The stress from academic failures, coupled with personal tragedies like the death of my grandmother and my own miscarriage, compounded my struggles. I reached the aggregate limit for federal student loans, leaving me financially strained as I pursue other graduate education. To top it off, there was a mistaken degree grant that was later retracted, causing additional emotional distress (Snyder, 2024).

I relentlessly advocated for myself, understanding the systems and resources available, but even with that knowledge, I couldn’t get the help I needed. Despite good reviews from my clinical preceptors, my struggles with test-taking outweighed my proven abilities in clinical settings. And that was the deciding factor in my dismissal from the program.

The Irony of the Mission

Ironically, the UW-Madison PA program emphasizes its mission to support students from diverse and disadvantaged backgrounds. They aim to recruit students from Health Profession Shortage Areas (HPSA), medically underserved communities, economically disadvantaged backgrounds, first-generation college students, and veterans. However, my experience suggests a disconnect between the program's mission and its support systems (UW-Madison PA Program, 2023).

The Mistaken Degree Grant

Trying to make the most of my circumstances and move forward in life, I requested a general master's degree since I had completed all didactic requirements. I hoped this degree would allow me to apply to DrPH programs without needing another master’s degree. A week later, despite no response from the dean, I received a diploma in the mail. Believing it was granted based on my request, I waited a few days to share the news to ensure it wasn't a mistake. After no additional correspondence, I shared the news with my social circles and my employer. Two days later, I received an email stating the degree grant was a mistake on the program's end and they were "sorry for the oversight." (Snyder Appeal, 2024).

Further more, when expressing concern to the Academic Dean, not only regarding this unfortunate mistake, but also in relation to feeling as though I had been discriminated against because of a medical condition, there was no sincereity, seriousness, or indication of intention to further investigate. Instead, it was a mere "I'm sorry you feel traumatized by the PA program and our university.". No follow up questions, sharing of resources or contacts to reach out to regarding my concerns. If you ask me, I was met with nothing other than beuracratic jargon, blanketing the systemic oppression lurking at deeper levels. 

Lack of Early Intervention

My experience also highlighted a lack of early intervention from the program. Despite multiple emails to my mentor and faculty, reaching out to describe my efforts to combat various challenges and asking for additional resources, I did not receive the support I needed. Had a leave of absence (LOA) or other resources been offered earlier, it might have prevented the high stakes I faced in my testing. The pressure of knowing I was at risk of failing out of a program I had worked so hard not only to get accepted to, but to complete—including all didactic requirements and a capstone paper—was overwhelming. Without that pressure, and with earlier intervention, my outcome might have been different.

The Bigger Picture: Domestic Violence and Systemic Failures

The intersection of domestic violence, my academic struggles, and systemic failures paints a much broader picture. Domestic violence doesn’t just affect the immediate victim; it reverberates through families, communities, and institutions. In my case, trying to support my mother during her abusive relationship took an immense toll on my mental health and academic performance. I sought help from legal officials, but the response I received was infuriating: "I don’t know what to tell you." Despite a supervisor admitting they were aware of the abusive officer’s behavior, no action was taken.

Domestic violence is a public health crisis. According to the CDC, one in four women and one in ten men will experience intimate partner violence in their lifetimes (CDC, 2022). The ripple effects of domestic violence extend beyond the home, affecting mental health, economic stability, and access to education. In my case, it compounded my struggles in PA school and further strained my already limited financial resources.

A Call to Combat Domestic Violence

To address domestic violence, we need to implement evidence-based strategies that take a holistic approach to prevention, intervention, and recovery:

1. Trauma-Informed Care in Healthcare and Education: Schools and healthcare systems must adopt trauma-informed practices that recognize the deep and lasting effects of domestic violence and trauma. This includes training educators, healthcare professionals, and legal officials to provide better support to those experiencing trauma.

2. Stronger Legal Protections and Enforcement: We need stronger enforcement of legal protections for domestic violence victims. The fact that I was told by a high-level government official, "I don’t know what to tell you," speaks to the failure of legal systems to protect victims. Law enforcement must be held accountable, especially when they are the perpetrators of abuse.

3. Access to Mental Health Resources: Domestic violence survivors and their families need better access to mental health services, both in schools and communities. Offering comprehensive mental health support can reduce the long-term impact of trauma and improve educational outcomes for students facing these challenges.

4. Support Systems for Students Affected by Domestic Violence: Educational institutions should establish support systems for students impacted by domestic violence, including financial assistance, leave of absence policies, and on-campus counseling services.

Finding a New Path

While this experience has been incredibly challenging and traumatic, it has also helped me grow my purpose and vision. A lecture on epidemiology and my forced, and, in my personal opinion, unethical dismissal from the program opened my eyes to how I can still utilize my knowledge and experience from PA school and beyond. I've realized that only 20% of the factors that impact our health happen in clinics, while 80% need to be addressed outside the healthcare system from a unique and multidimensional lens.

I’m excited as I recently started an MPH program at Elmhurst University with a concentration in Leadership and Innovation. This program will help me understand how to make the changes I want to see and know patients need outside of the healthcare system. My goal is to use my talents, gifts, and abilities to meet people where they are and help them get to where they want to be, outside the traditional healthcare system.

For me, purpose means meeting people where they are and making them feel completely seen, heard, and valued—not just another number. When people feel seen and heard, it can significantly improve their health. Research shows that patients who feel their healthcare providers listen to them are more likely to adhere to treatment plans and have better health outcomes. For instance, a study found that patients who reported their doctors listened to them had a 12% lower risk of hospitalization and a 15% lower risk of death (Stewart, 1995). Another study highlighted that empathetic communication from providers can improve patient satisfaction, compliance, and overall health outcomes (Hojat et al., 2011).

I plan to use a unique approach to my work, emphasizing core values, resilience, health literacy, and trauma-informed care to address issues holistically and decrease barriers to care. I’m excited to let my gift in the art of medicine shine and lead me forward as I build a multifaceted business model throughout and alongside my time at Elmhurst University.

Looking Forward

Discrimination and mistreatment remain significant issues within medical, PA, and NP education. Students from underrepresented groups who report such experiences have higher attrition rates. For example, students reporting recurrent mistreatment have an attrition rate of 4.1%, compared to 1.2% for those who did not report mistreatment. This not only affects the diversity of the healthcare workforce but also exacerbates the overall shortage of professionals (Med School Insiders, 2023).

Solutions and Recommendations

Addressing these issues requires systemic changes across medical, PA, and NP education programs:

• Increase Support for Mental Health: Institutions should provide robust mental health support and accommodations for students with disabilities.
• Revise Evaluation Systems: Reducing reliance on standardized tests and incorporating holistic evaluation methods can help identify and nurture well-rounded healthcare providers.
• Expand Residency and Clinical Training Slots: Increasing the number of residency and clinical training slots can address the bottleneck in training more professionals.
• Combat Discrimination: Implementing stricter policies against discrimination and providing support for underrepresented groups can reduce attrition rates and promote a more diverse healthcare workforce.
• Advance Research: Continue and advance research on this topic to identify a framework for future improvements.
• Standardize Curriculum Requirements: Establish standardized curriculum requirements to ensure fairness, such as how practice PAEA exams are used across programs.
• Assessment Tools: Develop assessments or conversational tools to help faculty identify students who may need more resources, including academic capabilities, accommodations, and personal circumstances.
• Early Mental Health Support: Address mental health, learning, and other disabilities from a young age to prepare students for the challenges of graduate studies.
• Enhanced Collaboration: Promote more collaboration between mentors and other resources, both within and outside universities.
• Combat Imposter Syndrome: Implement effective strategies to help students combat imposter syndrome.
• Financial Support: Find ways to lessen financial constraints on students during and after schooling.
• Embrace Diversity: Accept and honor diversity in students' personal and professional lives, without limiting them because of their lives outside of school.
• Challenge Hustle Culture: Fight and combat the "hustle" and "never enough" culture and mindset.
• Resilient Parenting and Growth Mindset: Encourage resilient parenting and growth mindset teaching from a young age to help children develop coping skills and resilience early on.
• Address Community Traumas: Address community traumas such as Adverse Childhood Experiences (ACEs) to prevent mental health issues from a young age and improve long-term health outcomes.
• Combat Domestic Violence: Schools, healthcare systems, and legal institutions must take a stand against domestic violence by providing trauma-informed support, holding perpetrators accountable, and offering accessible mental health resources for victims and their families

By making these changes, educational institutions can help ensure a steady and diverse pipeline of healthcare professionals ready to meet the growing demands of the U.S. healthcare system.

Disclaimer: The intent of this writing is not to solely focus on and talk negatively about UW-Madison, nor speaking on behalf of the institution as a whole - just speaking from my personal experience. This personal experience is being shared to shine a light on a significant issue the U.S. healthcare system is currently facing and to open the conversation for how we can better support our students, who in turn can provide better care for our patients. None of this is to excuse or stray away from accountability for me failing my exams. It is to highlight points where there could be improvement for the future and examine ways we can do better for our students because they deserve it and our healthcare system is in desperate need of medical professionals.

Join the Conversation

I’d love to hear from you! Have you faced similar challenges in your medical, PA, or NP program? Have you experienced the impacts of domestic violence or trauma while navigating your education or career? Do you have ideas for improvement or ways to better support students and survivors?

Please share your experiences and thoughts in the comments below. Let’s work together to create a supportive, trauma-informed, and inclusive educational environment for all future healthcare professionals.

With Love and Hope for the Future,

Hailey Snyder

The Unlicensed PA 

References:

Dreher, H. M., & Srinivas, T. (2017). Psychological stress experienced by nurse practitioner students. Journal of Nursing Education, 56(4), 222-227. https://doi.org/10.3928/01484834-20170323-08

Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella, J. S. (2011). Physicians' empathy and clinical outcomes for diabetic patients. Academic Medicine, 86(3), 359-364. https://doi.org/10.1097/ACM.0b013e3182086fe1

Medical Economics. (2023). Nurse practitioner report calls for urgent change to NP education. Medical Economics. https://www.medicaleconomics.com

Med School Insiders. (2023). US medical school dropout rates & why students drop out. Med School Insiders. https://www.medschoolinsiders.com

National Commission on Certification of Physician Assistants (NCCPA). (2023). PANCE performance summary report. NCCPA. https://www.nccpa.net/pance-performance-summary

NursingProcess.org. (2023). 25 important current issues facing nurse practitioners. NursingProcess.org. https://www.nursingprocess.org/issues-facing-nurse-practitioners.html

Physician Assistant Education Association (PAEA). (2022). Program report 35: Data from the 2021 matriculating student and end of curriculum surveys. Physician Assistant Education Association. https://paeaonline.org

Rotenstein, L. S., Ramos, M. A., Torre, M., Segal, J. B., Peluso, M. J., Guille, C., & Mata, D. A. (2016). Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA, 316(21), 2214-2236. https://doi.org/10.1001/jama.2016.17324

Snyder, H. (2024). HSNYDER_PASchoolSummary. Personal document.

Stewart, M. A. (1995). Effective physician-patient communication and health outcomes: A review. CMAJ, 152(9), 1423-1433. https://doi.org/10.1186/1472-6963-9-109

The PA Life. (2023). PA school ranking by PANCE pass rates. The PA Life. https://www.thepalife.com/pance-pass-rates

University of Saint Francis. (2023). Class of 2023 attrition rate. University of Saint Francis. https://www.saintfrancis.edu/pance-performance-report

UW-Madison School of Medicine and Public Health. (2023). Physician assistant program goals and outcomes. UW-Madison School of Medicine and Public Health. https://www.med.wisc.edu/education/pa-program/goals-outcomes