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Premed...Prepare: Premedical Education and its Impact on Undergraduate Education

dfishervan's picture

Dakota Fisher-Vance

Biology and Society Senior Seminar

Professor Grobstein

16 October 2010

            Every fall, thousands of eager students crowd into introductory chemistry, physics, and biology lecture halls with the intention of embarking on the daunting quest to become a physician. For undergraduates hoping to graduate from an American medical school, this expedition begins with the completion of the premedical requirements which include a year of physics, general chemistry, organic chemistry, biology, math, and English and culminates in the Medical College Admissions Test (MCAT), and exam designed to evaluate students’ knowledge of the premedical subjects. Students are content filling up their schedules with these prescribed courses as long as it gets them one step closer to medical school and the rest of society is simply content respecting these premedical students for daring to tackle such a rigorous schedule. However, considering the fact that in a few decades, we will place our health in the hands of those premedical students who survive the requirements and the selection hand of medical school admissions committees, one would think society would be more concerned with the elements of their training. Recent studies have brought the current premedical requirements under scrutiny and encouraged society to reconsider how to best prepare these future physicians who will eventually be responsible for medically advising society. While studies have demonstrated a correlation between MCAT scores and step one U.S. Medical Licensing Exam scores, another study has drawn into question the necessity of the MCAT and premedical requirements by concluding that Mount Sinai medical students who did not take the MCAT or the premedical course load performed just as well as traditional medical students before and after graduation (Julian 2005; Muller et al. 2010). By examining the relationship between the premedical requirements and undergraduate education, this paper will show the negative impact of these requirements on both premed and non-premed students and will demonstrate the need to revise the current premedical curriculum.

            In order to better assess the effects of the current premedical curriculum, there exists a need for one to understand the origins of premedical education. Initially, the only prerequisite for medical school was a monetary one. Throughout the 19th century, most medical schools lacked financial resources and thus willingly welcomed any male student capable of affording tuition regardless of his educational background (Apte 2009). Johns Hopkins University Medical School proved to be one of the few exceptions. In 1878, 15 years prior to the opening of its medical school, Johns Hopkins University developed a unique, lengthy list of hard science courses to be completed by students hoping to enroll in medical school (Fishbein 2001). While touring all of the North American medical schools in the early 20th century, Abraham Flexner, a noted scientist and educator, was most likely influenced by Johns Hopkins’ premature premedical curriculum. Like the founders of Johns Hopkins, Flexner advocated for the incorporation of science courses into medical training as he believed that physicians utilized the observation skills gained from laboratory work (Apte 2009). Flexner harshly criticized several aspects of the existing medical schools including their lack of admissions standards and set out to standardize premedical and medical education in his revolutionary 1910 report, “Medical Education in the United States and Canada” (Apte 2009). The work of Flexner resulted in the establishment of a formal premedical curriculum in 1930 which, with the exception of the English and math requirement, resembled the modern day curriculum (Apte 2009). The MCAT, originally known as the “Moss Test,” was first introduced in 1928 to lower medical school attrition rates and continues to play a significant role in medical school admissions decisions (Apte 2009).

            The use and weight of the MCAT in admissions decisions has adversely affected undergraduate education. To avoid hindering their students’ chances of medical school acceptance by neglecting to cover testable material, professors allow the MCAT to dictate their introductory science curriculums. A 2003 faculty survey revealed that undergraduate introductory courses sufficiently cover material considered essential by medical schools (Labov 2005). However, this achievement comes at a cost since faculty members must eliminate topics that they deem essential in order to include all of the MCAT material. Consequently, premed and non-premed students are not exposed to certain fundamental concepts necessary for other career paths such as research. Furthermore, some professors feel that they their curriculum sacrifices promote material that is no longer relevant for the practice of modern medicine (Arnaud 2009). After all, how often do doctors today rely on their knowledge of the Dies-Alder reaction? Some argue that this basic science education helps physicians adapt to the changing medical field by familiarizing them with the underlying science behind new medicinal technology (Arnaud 2009). However, one must question the ability of these premedical courses to convey the basic science appropriate for the continuously evolving medical field if the premedical requirements remain static for another century. A Haverford College professor noted the constraints imposed on undergraduate science courses by the unchanging nature of premedical requirements by stating “we have pretty much been teaching the first two years of introductory courses the same way for decades” (Arnaud 2009).

            To liberate undergraduate science courses from these constraints, Lewis Thomas, author of “How to Fix the Premedical Curriculum,” proposes the elimination of the MCAT and the premedical requirements that it tests (Gross et al. 2008). Other less radical critics hope to remedy the situation by substituting a few premedical requirements with humanities courses or condensing the premedical curriculum (Gross et al. 2008). While these two approaches differ in their degree of severity, they share the same goal. America invented the liberal arts education and encourages its premedical students to acquire such a liberal education. However, in addition to the typical liberal arts general education requirements, premedical students must load their schedules with an overwhelming number of science courses and “shifting too much science into college inevitably undermines a truly liberal education” (Gunderman et al. 2008). These two approaches look to incorporate and restore the liberal arts aspect of premedical education by diluting the premed student’s schedule with non-science classes. By diversifying their course load, Thomas and other critics hope to re-humanize the premed population. Thomas’ ideal premedical curriculum centers around classical studies, a subject which ironically helped spark the creation of the original science-oriented premedical requirements since Flexner and the founders of Johns Hopkins Medical School considered it useless in premedical training (Gunderman et al. 2008; Fishbein 2001). According to Thomas, a physician must possess knowledge of what it means to be a human and he believes that classics courses will help premedical students achieve this essential understanding (Gunderman et al. 2008). Encouraging premed students to stray away from a course load dominated by science courses also helps ensure that these students will be challenged and stimulated by the basic science, pre-clinical portion of medical school (Gunderman et al. 2008).

            However, some critics insist that altering the premedical curriculum’s content would be ineffective and instead argue that this premedical problem stems from the lessons learned from the premedical culture, not curriculum (Gross et al. 2008). Due to the increased selectivity of medical schools, the premedical world has transformed into a hyper-competitive one complete with a gargantuan list of required courses. At some point, premed students stopped appreciating these courses as opportunities to learn and instead began to view them as merely boxes that needed checking off. Premed students no longer use biology courses and hospital volunteer work to assess their personal compatibility with the medical field. Throughout their undergraduate years, these students are inducted into this premed culture where they learn how to put on a show for the medical admissions committee. Rather than building character, premed students learn how to demonstrate character (Gross et al. 2008). Of course, one cannot completely blame the student for the development of this conniving attitude towards premedical education. Pre-health advisors and websites contribute substantially to the premedical culture and thus influence the behavior of premedical students. While the majority of pre-health websites list all of the premed requirements, very few attempt to explain why these requirements exist. Although UCLA’s pre-health page first reasons that the premed requirements exist so that students can “confirm their interest and capacity for proceeding further in these fields,” it goes on to strategically remind students that medical schools use these requirements as a means of assessment (“Pre-Health Career Services” 2010). Students quickly forget about the fact that the premed requirements were designed for their benefit as they frantically strategize about ways to pass the “assessment.” In order to encourage students to take advantage of the premedical journey rather than rush through it, critics suggest the creation of a medical admissions test that also evaluates a person’s noncognitive attributes (Gross et al. 2008).

            The most recent evaluation of the current premedical education emphasized a more content-oriented reform. In June 2009, the Association of American Medical Colleges and Howard Hughes Medical Institute released “Scientific Foundations for Future Physicians” which proposed redesigning premedical and medical education to make them more competency-based (Eisen 2009). The report outlines eight competencies which every premedical student should understand upon graduation (Eisen 2009). These competencies focus on applying basic medically relevant skills and lead to the “study of concepts underlying medicine” (Eisen 2009). This report hopes to convey these competencies via a wide range of interdisciplinary courses that allow students to recognize the material’s biomedical relevance while teaching them how to solve problems by combining various disciplines (Eisen 2009). This reform has the potential to benefit premed students as it would give them more flexibility in course selection and would discourage the compartmentalization of sciences traditionally employed by students studying for individual MCAT subjects. The proposed plan also appeals to educators yearning for the freedom to redesign their introductory science curriculums. However, this freedom would most likely be short-lived since these new premedical competencies would eventually replace the premedical requirements currently constraining introductory science curriculums. While these new science courses may initially attract more non-premed students, they still cater to premed students and would thus continue to deprive non-premed students of certain fundamental concepts. Additionally, this proposed premedical plan fails to address how to avoid students mindlessly checking off each competency requirement without reflecting on the premedical journey.

            Completion of the premedical curriculum constitutes one piece of training for future doctors and thus affects all members of society planning on seeking medical advice in the decades to come. For this reason, it is imperative to consistently reevaluate the premedical education by examining the premed content as well as the premed attitude. Ultimately, undergraduate institutions must provide a premedical education that best prepares a premedical student to abandon the “pre” and assume the role of medical student.




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Paul Grobstein's picture

Biology and premedical education

I have a sense of two somewhat distinct problems here, and would be interested in hearing more about each of them and, in particular, how distinct they actually are: can solutions be found for the "premed culture" problem independently of the impact of medical school requirements on biological curricular generally problem or are they importantly related?  In addition, I'm curious about the relation between both and what seems to me a somewhat neglected aspect of this analysis: the impact of existing college education arrangements on the quality of medicine and health care.  Do the proposed revisions reflect explicit dissatisfactions along those lines or are the mostly otherwise motivated? 

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