Abstract: Med and dental school admissions committees and references have been asked to assess an applicant’s “self-awareness” as an entering competency for medical and dental school, shifting away from explicitly evaluating cultural humility. However, as self-awareness remains a focus for leadership development for senior educators and leaders, it is not realistic that students should strive to be “masters” at this competency as applicants. This article argues that self-accountability is a more desirable and observable competency, and provides several assessment tools to explore cultural humility and self-awareness/accountability.

Background

In 2026, the AAMC Mission-Aligned Recruitment and Retention team identified Self-Awareness as a professional competency desired for entering medical students. It replaced “cultural humility”¹ to include a greater awareness of one’s own background and journey when developing a professional identity as a future physician. In this article, I argue that “self-accountability and integrity” is a more measurable competency that can be demonstrated through activities and actions. Independently, beginning in 2026-2027, AADSAS evaluations include a rubric to characterize an applicant’s self-awareness along with nine other desired competencies.²

How do admissions professionals evaluate self-awareness? I will discuss how the self-awareness standard differs from “cultural humility and awareness,” the previous competency, and why self-accountability and integrity are likely more desirable attributes that evaluators can better observe.

What is Self-Awareness?

The change in terminology signals a change to a more intrinsic focus. Self-awareness gauges how one thinks about and thrives in their native environment. As you consider life choices (hobbies, career goals, academic performance), you should become more aware of your emotions, relationships, and finances that shape your growth and life philosophy.

Self-awareness focuses on the skills that identify your values, strengths, needs, behaviors, and biases as you navigate your environment. While I have previously discussed the OCEAN personality traits³ that can be measured in memoirs or personal social media posts, we see many students relying on personality assessments to begin outlining their preparation for a health professional career (for example, via the VIA Character Strengths Inventory⁴).

Self-care focuses on behaviors that result from self-awareness. Exercise routines, dietary discipline, meditation, or artistic expression are commonly cited as ways to achieve some balance or manage stress.⁵ One can build greater self-awareness through discussions of philosophical texts,⁶ emotional intelligence assessments,⁷ situational judgment tests,⁸ and introspective practices such as journaling.⁹

Finally, “self-awareness” embraces the humanity of healthcare professionals that AI models cannot fully emulate. Self-awareness is debated as a distinguishing attribute lacking in artificial intelligence models. While AI programs may communicate emotively to adjust to a user’s preferences, they mimic emotions based on their training data rather than as an organic feeling or reaction. Programmers remain challenged to see if an AI program can develop feelings or a sense of morality on its own. While one can train an AI bot on the fundamentals of medical ethics, health professionals’ self-awareness should make human providers indispensable.

In contrast, cultural humility acknowledges external systems and structures that shape communities. A goldfish living in a bowl may have self-awareness of its own environment of light, food, and clean water, but may not have the “cultural humility” to know that different goldfish may live differently, with infrequent feeding or bowl cleaning.

How Health Professions Programs Emphasize Self-Awareness

Most applicants notice that self-awareness is not identified as a core value or desired attribute. “Self-care” is mentioned in three program mission statements (Alice Walton, Alix Mayo Clinic, and and Robert Wood Johnson Rutgers), but “self-directed” is mentioned in four (Pritzker University of Chicago, University of Illinois, Washington University St. Louis, and Ohio State University). It is less clear how self-awareness is reinforced or further taught in medical schools. Most efforts in self-awareness may be presented as a mindfulness/flourishing, or resilience-building module within a professional identity formation program.

Interestingly, the Floyd Washington State University School of Medicine discusses Medical School Professionalism and Self-Awareness in its Student Handbook,¹⁰ making self-awareness a necessary component for emulating integrity, respect for others, and humility in a privileged role. They specifically call out a practice of “self-awareness, self-monitoring, and self-governance.”

Self-Accountability as an Observable Competency

Demonstrating self-awareness requires setting expectations and goals that reinforce one’s self-image, values, and vision. To achieve these goals, you must establish patterns or systems to monitor progress and remain accountable until you meet or change your final objectives. As suggested in the 2025 HPSA Profile of the Accepted Applicant,¹¹ successful prehealth students find themselves in supportive communities that help one another achieve their goals.

When applicants are asked to explain personal weaknesses, bad grades, or institutional action citations, interviewers seek evidence of the candidate’s self-accountability by accepting the outcomes of previous choices and creating new systems to actively monitor their improvement. Candidates may also embrace a role as an accountability partner to help others avoid similar mistakes or support others’ recovery from them. Consequently, accountability overlaps with a “commitment to learning and growth” and embracing an “ethical responsibility for self and others.”

Pharmacy educators list three progressive stages that can frame self-assessment evaluations: valuing and internalizing, defining and modeling, and opportunities and practicing.¹² Students can observe their progress in self-assessment by documenting entrustable activities in self-reflections, portfolios, and mentoring conversations.

Systems that Support Self-Accountability

One can measure self-accountability by identifying intentional practices through self-assessments and 360-degree feedback from other observers. The 20-question Personal Accountability Self-assessment¹³ may serve as a conversation starter for identifying self-accountability strengths and weaknesses to include in your letters of recommendation. Ask what assessment inventories are used at your desired programs to frequently monitor and discuss ways to become more self-aware and accountable; how do these self-reporting tools contribute to subsequent comprehensive evaluations for residency or graduate training?

Because of the revised focus on “Self-Awareness” and “Understanding Others,” I now presume that Cultural Awareness and Cultural Humility are desirable additional competencies.¹⁴ While “self-awareness” rewards efforts focused on self-discovery by “looking in a mirror,” the ability to see one’s journey in a broader context may be valued only to determine program fit and mission alignment. Programs must articulate how their curricula and student support systems nurture self-awareness and understanding of others for professional development among learners, staff, and faculty (for example, AAMC Aspiring Docs, ScribeMD¹⁵). Measurable outcomes of how self-awareness workshops improve the learning environment and leadership effectiveness in health professions programs are unclear, and prospective applicants should ask how their program leadership is accountable for their own self-awareness as a model for their learners and faculty peers.

Conflict of Interest Disclosure

The author serves as Director of Advising Services for the Health Professional Student Association, which publishes SDN Review and produces the HPSA Profile of the Accepted Applicant referenced in this article.

AI Use

Many resources were found through searches mediated through Claude, Gemini, and Perplexity. The author wrote the abstract, initial drafts, and resource descriptions, with editing facilitated by Grammarly.

References

1. Association of American Medical Colleges. Premed competencies for entering medical students. AAMC; 2026. Accessed April 20, 2026. https://students-residents.aamc.org/real-stories-demonstrating-premed-competencies/premed-competencies-entering-medical-students (opens in new tab)
2. American Dental Education Association. ADEA AADSAS resources and FAQs, 2026-2027. ADEA GoDental. Accessed April 21, 2026. https://www.adea.org/godental/Apply/resources-and-faqs (opens in new tab)
3. Chuck E. Getting to know you with the Big Five personality traits. Student Doctor Network Review; 2025. https://www.studentdoctor.net/2025/07/10/getting-to-know-you-with-the-big-five-personality-traits/
4. VIA Institute on Character. VIA Character Strengths Inventory. Accessed April 20, 2026. https://www.viacharacter.org/ (opens in new tab)
5. Student Doctor Network. Thriving in school: integrating stress intervention practices; 2015. https://www.studentdoctor.net/2015/03/24/thriving-in-school-integrating-stress-intervention-practices/
6. Student Doctor Network. The meaning of life: finding insights in the humanities; 2024. https://www.studentdoctor.net/2024/11/21/the-meaning-of-life-finding-insights-in-the-humanities/
7. American Medical Association. Should medical school applicants be tested for emotional intelligence? AMA Journal of Ethics; 2006. https://journalofethics.ama-assn.org/article/should-medical-school-applicants-be-tested-emotional-intelligence/2006-07 (opens in new tab)
8. Student Doctor Network. Show me about yourself: virtual interviewing platforms for health professions programs; 2021. https://www.studentdoctor.net/2021/12/11/show-me-about-yourself-virtual-interviewing-platforms-for-health-professions-programs/
9. Student Doctor Network. Practicing the art of reflection with a prehealth journal, podcast, or online blog; 2024. https://www.studentdoctor.net/2024/10/31/practicing-the-art-of-reflection-with-a-prehealth-journal-or-podcast-or-online-blog/
10. Washington State University Elson S. Floyd College of Medicine. Professionalism and self-awareness. Student handbook. Accessed April 21, 2026. https://medicine.wsu.edu/md/student-affairs/student-handbook/professionalism/ (opens in new tab)
11. Health Professional Student Association. 2025 HPSA profile of the accepted applicant. HPSA; 2025. https://www.hpsa.org/wp-content/uploads/2025/10/Profile_of_the_Accepted_Applicant_2025.pdf (opens in new tab)
12. Odem S, Kellett K, Maxwell W, Whalen K. Best practices for self-awareness and professionalism to meet the curriculum outcomes and entrustable professional activities. American Journal of Pharmaceutical Education. 2025;89(5). https://www.ajpe.org/article/S0002-9459(25)00049-X/abstract (opens in new tab)
13. Pharmacological Sciences Training Program, University of Michigan. Personal accountability self-assessment; 2014. https://medschool.umich.edu/sites/default/files/2023-08/Personal%20Accountability.pdf (opens in new tab)
14. Student Doctor Network. How to assess your pre-professional competencies; 2024. https://www.studentdoctor.net/2024/03/15/how-to-assess-your-pre-professional-competencies/
15. Association of American Medical Colleges. ScribeMD self-reflection program for medical students. AAMC Aspiring Docs. https://students-residents.aamc.org/medical-student-well-being/scribemd-self-reflection-program-medical-students (opens in new tab)

Abstract: This study analyzes the “OB3 Effect” via the HPSA 2025–2026 Applicant Experience Survey, examining how capping federal loans and eliminating Grad PLUS impact professional health students. Findings reveal funding gaps, reliance on private loans—especially in dentistry—and shifts in applicants’ career choices, institutional enrollment preferences, and credit score vulnerabilities.

Note: On June 25, 2026, a federal judge temporarily blocked the Trump administration rule that determined eight professional programs, such as nursing, physical therapy, speech-language pathology, and physician assistant programs, were not “professional,” and thus not eligible for higher federal loan caps.

July 1, 2026, began a new chapter in higher education as provisions of the One Big Beautiful Bill of 2025 (OB3) went into effect. Federal subsidized loan limits on undergraduate, graduate, and professional programs, along with the elimination of the GradPLUS program, have created confusion and uncertainty about the impact of debt when choosing to attend a health professions program (including medicine, dentistry, veterinary medicine, etc.).

These results from the 2025-2026 HPSA Applicant Experience Survey shed light on reactions to these new limits and anticipated career choices as these incoming students balance their career aspirations with the realities of debt repayment. Results come from two surveys: the Fall 2025 survey was administered between November and December 2025, while the Spring 2026 survey was administered between April and May 2026. 

Concerns About OB3 Rules Change Effects

When we analyzed 62 responses (assisted by Claude AI), the Fall survey identified five major areas of concern with OB3. These concerns confirm the challenges that higher education advocates identified.

• Private loans (turning to private lenders)
• Affordability (how to pay, cost of attendance)
• Loan caps (funding gaps due to borrowing limits)
• Financial stress
• Solutions and scholarships (PSLF, HPSP, in-state options)

Our respondents accessed authoritative sources (Figure 1). Specifically, respondents sought updates on financing education from program, university, non-profit, and government websites (including studentaid.gov). Podcasts and videos, such as the White Coat Investor Podcast, were also popular. 

Respondents were concerned about the educational debt they would assume through their education (Figure 2). On a 10-point scale (0 was inconsequential, 10 was a significant concern that should dissuade one from applying), the median response was 5, but 7 had the highest number of respondents. A large number of respondents – many of whom self-reported taking 4 or more gap years – described their concerns at 2 or fewer.

Respondents self-reported their credit scores, though there seemed to be differences among applicant pools (Table 3). Medical school applicants self-report higher credit scores, while applicants to other health professions, such as dentistry and veterinary medicine, generally have lower scores. Credit scores may influence the terms applicants are offered for private loans to cover graduate or professional education.

Mission Fit and Money

Applicants were asked to identify three preferences that dictate their ideal programs (Figure 4). Applying to in-state programs that offer financial advantages was the top preference among respondents. Other popular choices include a program’s multiple opportunities to address community needs and its proximity to supportive family members or friends. Programs also appealed to respondents if they had many supportive mentors and role models who helped them build credibility as scholars or offered other impactful experiences.

Respondents further focused on keeping their upfront educational debts low (Figure 5). Accepted students prioritized attending programs that offered financial aid packages that resulted in the lowest possible debt. They also valued programs with the lowest cost of attendance and opportunities to reduce commuting or housing costs by leveraging family or support systems. A few indicated that they would choose programs with more opportunities to enter specialties that could pay more than primary care specialties, to pay off debts more quickly.

The estimated cost of first-year attendance was generally higher for incoming dental students than for medical or veterinary students (Table 6). The median accepted dental student’s first-year cost of attendance was estimated at $140,000. In contrast, the median accepted medical student’s first-year cost of attendance was $100,000. Veterinary medical students self-reported the lowest first-year cost of attendance at $72,000.

Only a quarter of respondents reported receiving scholarships in their financial aid package (Table 7). The amount given was more generous for incoming medical and veterinary students ($33,000 and $24,000, medians respectively) than for incoming dental students ($5,000). Reflecting the new federal loan caps, incoming medical and dental students report receiving the maximum loan amount of $50,000 (Table 8). Private loans were included in medical and dental student financial aid packages.  The amount taken by dental students was much higher ($50,000 median) than that of medical students ($8,000 median). Veterinary medical students self-report that their federal loan packages are below the limit, and they do not take out private loans.

Discussion: The Disproportionate Impact of OB3

These insights from the 2025-2026 Applicant Experience Surveys show that applicants are choosing programs with a lower cost of living, generous scholarships, and proximity to support systems to reduce housing or commuting costs. However, our results show that incoming dental students face higher attendance costs, smaller scholarships, and greater private loan burdens. Our respondent pool also showed that incoming dental students reported having lower credit scores, which exposes them to less favorable private loan packages during their education. In contrast, veterinary student respondents face the lowest costs of attendance, resulting in a larger proportion of student debt held in federally subsidized loans. Finally, the financial aid packages for incoming medical students seem to offer generous scholarships only to the top quartile of respondents. Consequently, most medical students may rely on private loans (upper quartile $40,000) to cover their first-year cost of attendance.

These concerns do not wane when applicants take gap/growth years before receiving an offer of admission. While financially independent students may have benefited from a few gap years’ worth of savings or stress relief, they share similar concerns about the amount of debt they take on for their education. Future applicants with limited financial resources may need to consider options for paying for their education, including scholarship programs such as the Health Professions Scholarship Program or the National Health Service Corps.

Generative AI Assistance

Generative AI tools helped with creating the Abstract (Gemini) and proofreading (Grammarly).

Correction

The date when the rule was stayed on June 25, 2026; previously, the wrong date was listed. More information about the ruling is found on the PAEA website.

Abstract: Test anxiety in medical school is a common challenge, driven by high-stakes assessment and amplified by generational mental health trends, social media influences, and lingering effects of COVID-related educational disruption. This article examines how performance pressure, imposter syndrome, and unfamiliar testing environments contribute to anxiety among medical students. It emphasizes that test anxiety is common and manageable through practical strategies, including attending to basic wellness needs, practicing with exam-style questions, simulating testing conditions, and using structured approaches during exams. Social connection and support are highlighted as key protective factors. The article reframes struggle as a normal and meaningful part of medical training, supporting resilience and sustained academic success.

It’s 8:00 a.m., and the final exam starts.

A student sits in a silent classroom staring at the first question on the screen. They studied for weeks. They know the material. But suddenly their mind goes blank. Their heart starts racing. Their thoughts spiral:

What if I fail? What if I don’t belong here? What if this one exam changes everything?

For many medical students, this moment feels all too familiar.

Test anxiety has always been part of rigorous academic environments. But in recent years, it has become one of the most common concerns students bring to my office. The anxiety itself isn’t new, but the intensity and frequency seem to be increasing.

Medical school is, by design, a high-pressure environment. But today’s students are navigating additional pressures that make test anxiety even more likely.

The encouraging news is that for most students, test anxiety is manageable. Understanding where it comes from, and learning how to prepare both academically and mentally, can make a significant difference.

Why Medical School Creates High-Stakes Pressure

Medical education is structured around a series of major performance checkpoints. A small number of high-stakes exams can significantly influence a student’s academic progression and career trajectory.

From admissions exams like the MCAT to licensing exams such as the USMLE Steps, success in medicine has long been tied to standardized test performance.

Within medical school, exams often determine whether a student progresses in a course, advances to the next semester, or, in some cases, faces probation.

That structure alone can generate significant pressure. But several other factors are amplifying test anxiety for today’s students.

The “Perfect Storm” Facing Today’s Medical Students

Most current medical students belong to Generation Z, a cohort that research suggests is experiencing higher levels of anxiety and depression than previous generations. According to a 2025 narrative review in the Journal of Child and Adolescent Psychiatric Nursing, anxiety is substantially more prevalent among Gen Z (generally defined as individuals born between 1997 and 2012) than in any of the three generations before them.

A 2023 Walton Family Foundation and Gallup survey reinforces this pattern. It found that Gen Z reports negative emotions, including anxiety, stress, sadness and loneliness, at rates at least 7 percentage points higher than millennials, Gen X, baby boomers and the Silent Generation. Only 15% of Gen Z ages 18 to 26 rated their mental health as excellent, compared with 52% of millennials at the same age a decade earlier.

For students entering demanding academic environments such as medical school, these broader mental health trends mean that many arrive already navigating significant stress and anxiety, conditions that can easily intensify in high-stakes testing environments.

There are many possible explanations for this, from economic uncertainty to the pace of modern life, but what we often see is a group of students entering an already demanding environment while also navigating broader mental health challenges.

Medical school can also be isolating. Students may be living away from home for the first time while managing an extremely rigorous academic workload.

At the same time, they’re constantly exposed to curated portrayals of medical school on social media.

Many students follow influencers who present highly polished glimpses of life as medical students or physicians. These snapshots can create unrealistic expectations about what medical training should feel like.

When students encounter the inevitable challenges of medical school, they may conclude that something is wrong with them rather than recognizing that difficulty is a normal part of the process.

The result can be what I often describe as a perfect storm for test anxiety.

The Rise of Imposter Syndrome

Test anxiety is often closely connected to imposter syndrome, the belief that one’s achievements are undeserved or that one will eventually be exposed as a fraud.

Students sometimes tell me:

“I studied so hard, and I got a C in the class. Maybe I’m not cut out for this.”

“Everyone else seems to be doing better than I am.”

“Maybe I don’t deserve to be here.”

What’s striking is that these feelings can persist even when students are progressing through the program successfully.

Part of the problem is the myth of the “perfect medical student.” Many students believe the ideal medical student earns all A’s and never struggles academically.

But that student doesn’t exist.

Medical school has always been difficult. Struggling in a course, or even struggling for a semester, does not mean you don’t belong in medicine.

Yet social media can make it feel otherwise. Students may sit in a challenging lecture where everyone seems confused, only to later see classmates posting online about how great the day was.

Your lived experience tells you the class was difficult, but the online narrative suggests everyone else is thriving. Over time, that disconnect can reinforce feelings of inadequacy.

The Lasting Effects of COVID on Test Anxiety

Another factor shaping this generation of students is the educational disruption caused by the COVID-19 pandemic.

Many students completed part of their high school or undergraduate education in remote environments. Exams were often taken at home rather than in traditional proctored settings.

Now they find themselves sitting in silent classrooms for hours at a time, taking high-stakes exams under strict conditions.

For some students, the testing environment itself becomes a source of anxiety.

I often hear students describe the exam room as “eerily quiet.” They’re not used to sitting in a rigid chair for several hours without looking around, checking their phone, or taking a break.

These environmental factors may seem minor, but they can contribute significantly to the stress of test day.

What Actually Helps Students Manage Test Anxiety

The encouraging reality is that most students can reduce test anxiety with a combination of preparation, self-care, and practical testing strategies.

1. Start With the Basics of Well-Being

One of the first things I look at with students is their basic wellness habits.

This might sound obvious, but many students neglect the fundamentals during exam periods. I often hear something like:

“I’ve slept two hours a night all week and I’m really anxious about this exam.”

At that point, anxiety is inevitable.

Students perform best when they prioritize:

• Adequate sleep
• Regular meals
• Hydration
• Movement and sunlight

These may seem like small things, but they form the foundation of cognitive performance. Pulling an all-nighter rarely leads to better exam outcomes.

2. Practice With Exam-Style Questions

Another important strategy is self-testing.

Students benefit greatly from practicing with multiple-choice questions throughout the learning process. This helps them move beyond memorizing information to understanding how concepts are applied clinically.

The goal is to avoid making connections for the first time during the exam itself.

Ideally, by test day students are simply showing up and performing what they’ve already practiced.

3. Mimic the Testing Environment

I also encourage students to practice under realistic testing conditions.

That means sitting in a quiet room, timing themselves, and completing a full practice exam when possible.

This serves two important purposes. First, it builds stamina. Medical exams can be long, and students need to practice maintaining focus for extended periods. Second, it removes surprises. If students have already practiced sitting in a silent room for several hours, the actual exam environment feels familiar rather than intimidating.

4. Have a Plan for When Anxiety Appears

Even well-prepared students may feel anxious during an exam.

The key is having a strategy.

Students who develop a systematic approach to answering questions are less likely to panic when anxiety arises. Instead of reacting emotionally, they can rely on the process they’ve practiced.

When anxiety appears, structure restores a sense of control.

5. Stay Connected

Finally, one of the most important protective factors against anxiety is social support.

Medical school can be isolating, particularly for students who are adjusting to new environments or living away from home for the first time.

Building relationships with classmates, mentors, family members, or counselors can provide essential grounding during stressful periods.

No one gets through medical school entirely alone.

A Different Way to Think About the Journey

One of the most important conversations I have with students is about expectations.

Many enter medical school believing they must excel at everything immediately. When that doesn’t happen, they assume they don’t belong.

But the reality is that medical school is meant to challenge you. Growth often happens precisely at the point where things feel difficult.

Struggling at times doesn’t mean you’re failing. It means you’re learning.

The Bottom Line

If you’re experiencing test anxiety in medical school, you’re not alone.

Many intelligent, capable students face the same challenge at some point in their training. The key is recognizing the anxiety early and developing strategies to manage it.

Medical school is demanding, but it’s also a process designed to shape resilient physicians.

You earned your place in this journey.

With the right preparation and the right perspective, you can learn to show up, perform, and succeed even in the moments that feel most intimidating.

Conflict of interest disclosure

The author reports no conflicts of interest.

AI use

The abstract summary was produced by the editors using Microsoft Copilot on April 25, 2026. No other part of this article was generated by AI.