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I had originally planned to take all of last week off, but a couple of topics popped up later in the week that were too good to ignore. Accordingly, the usual “readers respond” column had to wait.

First, many thanks to the readers who wrote in with thoughts on the M.D./M.P.H. dilemma that The Boy is facing. Advice was wide-ranging but consistently thoughtful and nuanced. I forwarded every single response to TB, who told me he will reach out to at least a few.

As a longtime friend noted at the end of a conversation on the topic, on which she is well prepared to speak, “this is social capital in action.” Well, yeah, so in the interest of openness and to avoid charges of opportunity hoarding, I’ll share a few key insights.

First, each degree serves a distinct purpose, so much depends on your goal. If the goal is to practice medicine, go for the M.D. An M.P.H. may or may not be helpful, but it’s a big endeavor if its only point is to help a med school application. A student who does something medical in a gap year—say, scribing—won’t be disadvantaged relative to one who did an M.P.H. Given that the former pays and the latter costs, getting an M.P.H. solely as a strategic move is probably not a great idea.

Second, if the goal is to work on health policy, it’s probably best to spend some time in the policy world first to see if you like it. Some people do, and some don’t. Volunteering on campaigns or working with a group whose goals are aligned with yours (such as an association of community health centers) can provide exposure to the reality of the field. I liked this point a lot. As I’ve mentioned before, it was through a summer internship in which I followed some lawyers around that I realized that I didn’t want to be a lawyer. We routinely get students who say they want to be teachers until they set foot in elementary school classrooms. There’s just no substitute for actual experience. TB already has experience as an EMT, so we know that he doesn’t faint at the sight of blood. If he finds the policy world congenial, then a subsequent M.P.H. may make sense, and an M.D. would be a very expensive distraction.

Finally, some places have good “joint” M.D./M.P.H. programs, but if you’re going to do that, a gap year is all the more important. Those programs are intense, so you need to be psychologically ready. After a rigorous college program, a break is in order. Burning out doesn’t help anybody.

TB is planning a gap year anyway, so he’ll have a chance to think through his options. In the meantime, thank you to everyone who answered the call.

In response to the piece about a teaching track for faculty, in which I noted that community colleges have been doing that for years, a few readers asked about how to evaluate teaching for purposes of tenure.

It’s a topic in itself, but my short answer is that in my experience, most faculty are at least pretty good at teaching, and most of those who aren’t could be with a bit of coaching. But there’s usually a bottom 5 percent or so that really needs to do something else. So it depends on whether you believe, philosophically, that the issue is optimization or harm reduction. I’m on the harm reduction side. With student course evaluations, for instance, I don’t pay any attention to variations within the top 90-plus percent of scores. I look for the ones who score multiple standard deviations below the mean semester after semester. Even there, scores should be taken as signs to look more closely, rather than as dispositive in themselves. Similarly, in cases of sequential courses—say, Chemistry 101-102—is there a consistent pattern of the students who had a particular professor for 101 underperforming everyone else in 102? If so, it’s a sign to look more closely. There may be other reasons for that—a distinct cohort, a scheduling issue—but it bears a closer look.

Improvement comes through collegial support and coaching. Negative decisions—which, yes, sometimes have to be made—need evidence.

If the goal is to be as exclusionary with teaching as the elites are with research production, then the community college model is likely irrelevant. But I respectfully suggest that we don’t have anything close to the certainty we’d need to do that, even if it were desirable. We do have the ability to find the ones who are bombing.

Finally, in response to the post about differential tuition by program, several readers made the excellent point that in the allied health field right now, there’s already significant racial and economic stratification by wage level: C.N.A.s are disproportionately women of color, and M.D.s are disproportionately white and Asian. Increasing the economic barrier to moving up would reinforce that stratification. That’s counter to the mission of public higher education. Yes, resources are tight, but asking those with the least to pay the most to improve their lot is not likely to end well.

Again, thanks to my wise and worldly readers for keeping me honest, bringing up perspectives other than mine and reaffirming my faith in reasoned discourse. It can be done.

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