Over the years, I have mentored medical students, residents, and early-career physicians on various issues ranging from wellness to career choices. I recently mentored a 26-year-old undergraduate student who had entered his senior year in college in 2021 and was applying to medical schools for the 2022 incoming year.
The student had a 4.0 GPA, 515 Medical College Admission Test (MCAT) score (90th percentile), and stellar references, including one from the president of his college. His interpersonal skills were excellent. He was definitely “worthy to serve the suffering.”(1)
The problem is, in 2015, the student had a serious addiction to opioids and was arrested on a felony residential burglary (no one was harmed). He believed he was fortunate to have been arrested because through the legal system, he was able to receive months of overdue rehabilitative treatment.
It was during treatment that the student first realized his passion for helping other individuals. He is in recovery and has an entirely new lease on life. His criminal record was sealed and is slated to be expunged in late 2022 or early 2023.
Applying to Medical School
The student applied to medical schools using the Association of American Medical Colleges’ (AAMC) American Medical College Application Service (AMCAS). He indicated he had never been convicted of a felony, in accordance with the AMCAS guidelines,(2) which state: “You must indicate if you have ever been convicted of, or pleaded guilty or no contest to, a felony crime, excluding (1) any offense for which you were adjudicated as a juvenile or (2) convictions that have been expunged or sealed by a court” [italics added]. He “passed” the AAMC-facilitated criminal background check.
However, the secondary applications the student received from medical schools asked very broad questions that superseded the AMCAS application, such as, “Have you ever been convicted of a crime or otherwise accepted responsibility for the commission of a crime?” or “Have you ever been charged with or convicted of any offense (in addition to the criminal activity that you may have already reported on your AMCAS application)?”
The student wanted to answer honestly, but he feared that in doing so, medical school admissions committees would view him prejudicially and reject him outright. He could have answered “no” from a legal perspective, based on his attorney’s letter that read, in part, “[The student] satisfactorily terminated from his probation, and on May 30, 2018, the court vacated [his] entry of guilt. Therefore, [he] does not have a felony conviction. As such, it would not be a falsification on an employment or educational application for [the student] to answer ‘no’ to a question asking whether he has been convicted of a felony, or otherwise not disclosing this case when asked about his conviction record.”
Despite his attorney’s interpretation of the law, the student was still uneasy answering “no” to questions that inquired about the commission of a felony. He recognized there could be repercussions by answering in the negative — for example, if his history was ever uncovered or his fingerprints inadvertently remained in the system once his record was expunged.
Seeking Guidance
To help the student decide whether to disclose his felony on the secondary applications, I sought the advice of three deans of U.S. medical schools. I asked them to draw on their experience with applicants in similar situations. None of the deans were affiliated with medical schools to which the student had applied.
In my email to them, I commented, “From everything I’ve read, there is still a bias against applicants with mental illnesses and substance use disorders, even those in recovery.” Here are the responses I received:
Dean One
“My short answer is that he should disclose. I think the field is changing, albeit slowly, and at least some schools will be able to look past this. I also think from a legal perspective that the way the question is phrased requires a ‘yes’ answer. Whether the records are sealed or not he was in fact arrested for a crime. I assume that also means conviction. If not convicted, he could legally answer ‘no.’
“I do not trust records being sealed, and there is a chance, albeit small, that this history could be revealed. We have had a couple situations in which seemingly stellar students had similar past incidents that they did not disclose, were subsequently revealed by various means, and the students’ opportunities were harmed by what was viewed as a lack of professionalism.
“I even wonder whether he should get out in front of this in his personal statement and neutralize the issue by making it the subject of his statement, what he learned, how he has changed, how it will make him a better physician. There’s always a risk, but I think that we should always err on the side of disclosure so as to open up this topic for proper discussion.”
Dean Two
“Yes, we had over the years a few like the one you described. My advice would for him to be honest and if there is an opportunity to give a narrative of ‘why I want to be doc,’ use it to tell his story. Any other course will lead to problems, to say nothing of never-ending anxiety. Is there a bias? Yes. But all it takes is one school to say yes. Would try to get the story out early under his terms. Good luck to this young man.”
Dean Three
“From my perspective, he needs to answer the question honestly and in the affirmative. This is both the correct answer and the ethically correct thing to do. Unfortunately, this may hurt him in his attempt to gain admission. That being said, it is also an opportunity to tell the story of his journey and the remarkable efforts he has made, his grit and determination, and the ways that his struggles will help him to become a more caring, compassionate physician.
“As I said, this could hurt him. However, if somehow a background check (they do these prior to entry to medical school) turns up a felony he hadn’t disclosed or somehow a school found out he wasn’t completely forthright, he could face serious adverse consequences that likely would end his medical school career.
“Sometimes things also seem to stay on the internet (things like arrest records, mug shots, etc.) in non-official places and get found on occasion by a classmate, a patient, etc. Even if he decided not to disclose (which I do not recommend), it is not clear that this will be expunged prior to his entry background check in the late spring/early summer of 2022, and it would not be well received by the institution if he had answered dishonestly. I think it is not unreasonable for him to also consult with an attorney.”
Additional Advice
I consulted one other individual via email: a colleague and authority on physicians’ mental health issues. He is also a member of the admissions committee of a medical school to which the student had not applied. I asked my colleague if he agreed with the opinions of the three deans. Here is his response:
“My sentiments are like the three deans, i.e., disclosure and transparency either in the personal statement or secondary application. This tells the admission committee a lot about the integrity of the applicant. Also, even if an applicant has not done anything wrong legally by not disclosing, the ethical churning and continuing angst about this coming out sometime down the road can be debilitating. And it might come out later given the climate in which we live and practice.
“Serving on our admissions committee for medical school since 2008 has given me a lot of experience with students disclosing lots of things, like underage drinking, cheating, plagiarism, shoplifting, etc., in college. In addition to growing through these ‘institutional actions,’ most feel relief in simply being open and free of the weight.”
The Decision
I shared the feedback of all four physicians with the student. He decided to disclose his felony conviction on the secondary applications, reasoning that failure to do so could have resulted in an offer of admission being rescinded if the omission were discovered, or he could have been disenrolled from medical school if the omission were discovered sometime later.
He did, however, include the aforementioned letter from his attorney explaining the nature of the crime and its legal disposition. The student was granted interviews at several medical schools, and he was accepted into the medical school of his first choice.
Criminal Behavior and Background Checks
There are three levels of convictions: (1) infractions, such as a speeding ticket; (2) misdemeanors, such as public intoxication; and (3) felonies, including assault. Infractions and misdemeanors are less serious than felonies and generally pose a lower risk to students wishing to matriculate in medical school unless students have an unusually high number of the same violations, which indicates they do not learn from their mistakes.
A felony is a criminal offense — including violent and nonviolent crimes — punishable by at least one year in prison. Felony convictions, although quite serious, are not all the same, and felony classes and punishments can vary from state to state.
Medical school admission committees will consider convicted felons on a case-by-case basis. Still, only about 1% of students with felony convictions gain admission to medical school,(3) whereas the average medical school acceptance rate is 7%.(4)
Despite projections emphasizing the need for more physicians to replace aging baby boomers, gaining acceptance into medical school has become increasingly difficult.(5) Critical factors that are driving the competition include(4,15):
The “Fauci Effect” — increased interest in medical careers attributed to the coronavirus pandemic.
More students applying — 62,443 total applicants for 2021–2022 — and applying to more schools (17 on average).
Earlier pre-med schooling — STEM programs as early as elementary school.
A plethora of top-notch applicants — test scores, grades, experiences, passion, and character.
Marginally higher acceptance rates — usually by 1% or 2% every year — with an overall average acceptance rate of 7% per medical school.
Relative lack of new schools due to inaccurately forecasted demand for physicians.
Most medical schools and some states require criminal background checks for all medical students. Additionally, hospitals and clinical institutions affiliated with many medical schools require criminal background checks for medical students completing clinical rotations at their facilities. The Department of Veterans Affairs mandates that all medical students involved in patient care at its hospitals undergo criminal background checks.
The rationale for criminal background checks for students entering medical school is based on the premise that it will strengthen the public’s trust in the medical profession, enhance the safety and well-being of patients, help the students become licensed physicians, and minimize the liability of medical schools and their affiliated clinical facilities. Some view criminal background checks as promoting professionalism insofar as background checks evaluate character by detecting crimes involving fraud and deceit.
Many medical schools use the following guidelines to assess potentially disqualifying criminal records:
The nature and seriousness of the crime, including whether the student has committed a crime of violence or a sex offense.
The circumstances under which the offense occurred.
The relationship between the offense and the student’s participation in the medical schools’ curriculum, including its clinical components.
The extent of the student’s past criminal activity and whether he or she is a repeat offender.
The age of the student when the crime was committed.
The amount of time that has elapsed since the student’s last criminal activity.
The conduct and work activity of the student before and after the criminal activity.
Whether the student has completed the terms of any probation or deferred adjudication.
Evidence of successful rehabilitation.
Forthrightness of the information about the incident in the opportunities for self-reporting.
Those who oppose criminal background checks argue that criminal records are often inaccurate and/or misleading, and criminal background checks promote racial injustices and disparities by disproportionately targeting socially disadvantaged ethnic minorities already underrepresented in the medical profession. There is no empirical evidence that criminal background checks will, in fact, improve patient safety, reduce unprofessional behavior by physicians, or enhance workplace safety or efficiency.
Harmful Use of Information
The Center for Community Alternatives (CCA), a New York-based public policy and advocacy organization, evaluated the use of criminal record histories in college admissions (but not in medical school admissions).
CCA found that less than half of the colleges that collect and use criminal justice information have written policies, and only 40% train staff on how to interpret such information.(6) Yet, a broad array of convictions are viewed as negative factors in the context of admissions decision-making, including common offenses such as drug and alcohol convictions, misdemeanor convictions, and youthful offender adjudications.
The center has recommended that colleges and universities refrain from collecting and using criminal justice information in the context of college admissions unless or until certain policies are in place to reduce the potential detrimental effects of criminal background checks in college applicants. It behooves medical schools to adopt their own policies and follow steps similar to those recommended at the college level, as shown in Table 1.
Advantageous Use of Criminal History
A US News & World Report article concluded, “Applying to medical school seems hard enough; with a criminal record it can be doubly so. The best way to deal with this issue is by explaining what happened and why, lessons you learned, and steps you’ve taken to ensure it will not be repeated.”(7)
This was clearly the consensus among the medical school deans, i.e., applicants should be truthful and honest and disclose a past history of criminal activity when asked. (Students are under no obligation, however, to voluntarily disclose past criminal behavior if they are not asked about it.)
Some students choose to make their crime the focus of their personal comments essay, as suggested by the deans, whereas others choose to address it on secondary applications, as did the student discussed here. He wrote, in part, “As a result of this extreme, unorthodox, and shameful past, I have developed my passion for helping others. I plan to use my empathy to serve as a physician dedicated to treating all patients with respect and dignity.”
Students who are forthcoming about their prior criminal activities may actually enhance their application to medical school if they can demonstrate in their essays that they have undergone a personal transformation that reflects positively on their personality, professionalism, and current lifestyle choices.
Social justice advocates have argued that convicted felons should receive a second chance for several reasons. First, most of their crimes were drug-related and committed when they were young and immature. Their interaction with the legal system and other authorities became a turning point in their lives and the nucleus for positive change. Unfortunately, the term “felon” followed them and marginalized them despite the overwhelming evidence that most people who have felony convictions can become constructive contributors to society.(10)
Second, doctors with criminal histories are uniquely positioned to provide counseling and empathy to patients who have committed crimes. Recovered physicians are likely to view offenders in non-judgmental terms, and the prospect of developing a long-term doctor-patient relationship may be more favorable when both parties share similar backgrounds.
Third, it is possible that a career in medicine can reverse early antisocial trends. Sigmund Freud wrote extensively on the process of sublimation — the appropriate channeling of unwanted impulses or urges. Through sublimation, people are able to transform those impulses into activities that are better for their health, or engage in behaviors that are positive, productive, and creative.
Freud’s concept of sublimation originated while he was reading the story of a surgeon who, as a child, had a penchant for docking the tails of dogs. The surgeon became a pioneer in rhinoplasty. Freud remarked, “There someone does the same thing during his whole lifetime, first out of sadistic mischief and later to the benefit of mankind.”(8)
Finally, accepting recovered students into medical school sends an important message to society. It reframes substance use disorders as mental health problems, as opposed to moral or criminal ones. The decriminalization of a medical problem increases access to treatment and lessens the stigma attached to it.(9) When substance use disorders are decriminalized, drug sales remain illegal, but the violation becomes a civil, not criminal, offense that may result in a fine or court-ordered therapy rather than incarceration.
Future Considerations
The undergraduate student I have been mentoring is aware of the challenges a prior conviction will have on his pursuit of a medical career. After he completes medical school, it is possible that his felony conviction, although sealed and expunged, will be revisited by states’ medical licensing boards by virtue of the open-ended nature of the questions asked on licensing applications, which may ignore or supplant any legal argument or disposition.
Medical boards have wide latitude in issuing licenses, and they appear to be primarily interested in “the effect of aberrant extraprofessional behavior on the trust the patient has in [their] personal doctor,”(11) regardless of the circumstances surrounding the aberrant behavior or the time at which it occurred.
In addition, a felony conviction can restrict or prohibit employment opportunities. The substantial investment required to become a doctor can be erased by a prior criminal conviction, even if that conviction has been vacated by the court. Thus, the value of hiring a seasoned, experienced and highly qualified attorney to assist individuals through the maze of considerations — from applying to medical school through applying to a job — cannot be understated. Physicians are advised to retain not only experienced criminal defense counsel, but also experienced counsel in medical board licensing matters who appears regularly before the medical board.
While it is important to remember that physicians have been known to engage in criminal activity, it is not known how their overall criminal activity rate compares to the general population.(12) Studies have shown that factors related to criminal activity in physicians include older age, lack of board certification, problem behavior in medical school, multiple failed licensing examination attempts, and specialization in family medicine and psychiatry.(13,14)
It is unknown whether physicians who have committed felonies before medical school and who subsequently entered the medical profession are disproportionately represented among physicians who have been disciplined for criminal activity while in practice.
Conclusion
This student’s acceptance into medical school highlights some of the tensions between the legal and medical systems. Legally, he was advised that because the court had vacated his guilty plea, technically he did not have a record of a felony conviction. The student recognized, however, that the morally responsible course of action was to acknowledge and address his past criminal behavior.
Non-disclosure of his crime on applications that called for disclosure could have put him on a collision course with medical authorities after he was accepted into medical school, and he could have suffered grave consequences, including dismissal from school, as discussed above.
To produce the healthcare professionals and medical researchers that society needs, diversity and inclusion efforts in medical schools and residency training programs must be championed. It is encouraging that medical schools across the country reported record increases in first-year Black and ethnic minority students for the 2021–2022 school year.(15) However, medical schools have yet to accord individuals recovered from substance use and mental health disorders similar parity.
Although this student’s acceptance into medical school suggests that past criminal behavior can be eclipsed by present character, the MCAT remains a normative marker in medical school admissions. Without an accomplished academic record, he likely would not have been considered a viable candidate for medical school and rejected on the basis of his qualifications alone.
Acknowledgment: I would like to thank my mentee for graciously allowing me to publish his story, which he hopes will serve as an inspiration to others who suffer substance use disorders and inspire them to consider careers in medicine. All names and identifying information have been omitted or modified to protect privacy.
References
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2022 AMCAS Applicant Guide. Association of American Medical Colleges. Washington, DC. Accessible at https://students-residents.aamc.org/media/11616/download .
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Prep V. Tips for Medical School Applicants with Criminal Records. US News & World Report. January 23, 2012. Accessible at www.usnews.com/education/blogs/medical-school-admissions-doctor/2012/01/23/tips-for-medical-school-applicants-with-criminal-records .
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Boyle P. Medical School Applicants and Enrollments Hit Record Highs; Underrepresented Minorities Lead the Surge. Association of American Medical Colleges. December 8, 2021. Accessible at www.aamc.org/news-insights/medical-school-applicants-and-enrollments-hit-record-highs-underrepresented-minorities-lead-surge .