The AMA Virtual Mentor web site has an interesting
and helpful variety of articles. They don’t seem to back away from
the controversial. You check what they have to say once or twice a month (new
issue online each month.)
Virtual Mentor
American Medical Association Journal of Ethics
November 2009, Volume 11, Number 11: 859-863.
MEDICAL EDUCATION
The Winnowing Fork of Premedical
Education: Are We Really Separating the Wheat from the Chaff?
Raymond G. De Vries, PhD, and Jeffrey Gross
It is Welcome Week 2009 at the University of Michigan
and we are sitting in a large room where 400 bright-eyed, first-year university
students are nervously chatting with each other, waiting for advice on how to
successfully navigate their premedical years. These eager young men and women
are getting the chance to meet their colleagues (competitors?) and to learn a
few facts about the medical school admission process.
Using an interactive PowerPoint presentation, the
organizers of the orientation offer information about life as premeds,
including (1) who their peers are (25.9 percent of students enrolled in the
College of Literature, Science, and Arts expressed an interest in a career in
health), (2) their likelihood of getting admitted to medical school (in 2008,
45 percent of the 42,231 applicants to medical schools in the United States
were admitted, and at the University of Michigan, 52 percent of those who
applied were admitted), (3) the co-curricular activities most desired by
medical school admission committees (shadowing, working in an emergency
department, helping disabled kids, doing research—although, if you must
choose, patient care is preferred over time in the lab), and (4) acceptable
reasons for delaying application to medical school past the junior or senior
years. An auditorium full of would-be doctors listens intently, scribbling
notes on the handouts provided at the door.
And so the premedical experience begins.
Flash back several months to the spring of 2009 and a
meeting on a different Midwestern campus. The attendees are medical school
faculty and residents; the topic is the use of narrative in the training of
medical students. The discussion centers on the sorry social skills of medical
students and the need to help the next generation of doctors remember that
patients are people with lives, emotions, and relationships—all of which
influence their health, the way they hear and interpret diagnoses and
recommendations for treatments, and their choice to comply or not comply with
medical advice. At one point, a faculty member asks: “What happened to
these students? Surely when they entered medical school, they were capable of
carrying on a conversation with other human beings.”
Well, maybe not. What happens to premeds? How do those
eager, high-achieving, gregarious first-year students, intent on careers in
medicine, become the drones that need corrective education in the humanities
during their medical school years?
www.virtualmentor.org Virtual Mentor, November 2009—Vol 11
859
Premedical
education has an important, but mostly unrecognized influence on the attitudes,
character, and moral lives of medical students. When medical educators think
about premedical education (which is not all that often) they focus their
attention on the substantive content of the premedical curriculum. The
“hidden premedical curriculum”—things learned indirectly from professors, advisors,
peers, relatives, books, the media, and extracurricular activities—is
ignored. If we wish to understand the character of first-year medical students,
we must first understand the many ways the experience of being a premedical
student influences not just performance on the Medical College Admissions Test
(MCAT), but ideas about success, relationships, and caring for others [1].
Although it is nearly 100 years old,
Abraham Flexner’s “Medical Education in the United States and
Canada” continues to exert a powerful influence on premedical education.
Before the Flexner Report, medical schools varied greatly in their entrance
requirements, curriculum, and quality of education [2]. Flexner’s desire
to bring medical education into the 20th century led him to promote a
standardized curriculum that gives “formal analytic reasoning, the kind
of thinking integral to the natural sciences…pride of place in the
intellectual training of physicians” [3]. The science-oriented premedical
curriculum found in virtually all undergraduate institutions today emerged as a
response to the need for premeds to prepare themselves for the new scientific
education offered by post-Flexner medical schools.
In the 10 decades since the
publication of the Flexner Report, there have been several efforts to reform
premedical education to make the premedical years more relevant to the work of
doctoring. Not surprisingly, reformers often disagreed about just what it was
that premedical students needed to learn. Some argued for eliminating a defined
premedical curriculum altogether, others called for a stronger emphasis on the humanities
and social sciences, and, recently, reformers have been making the case for
keeping the basic science focus of the curriculum, but with updated
requirements—including statistics, business management, and medical
ethics—required for the practice of 21st century medicine [4-8].
Notice that all these wished-for
changes in premedical education focus on the content of the curriculum and not
on the experience of being a premed. While we do not deny the value of
substantive preparation in the social and natural sciences and in the
humanities, we wish to point out that premedical students learn many lessons as
they prepare themselves, and their applications, for medical school. The
premedical experience—the strategies learned for succeeding in difficult
courses and for grooming one’s image for a medical school admission
committee—gives students a moral education, showing them what it takes to
get ahead, what it takes to become a doctor.
In our review of the guidance given
to students on their college’s premedical advising web sites we noticed a
subtle but important distinction between developing
and demonstrating character
[1]. Premedical advisors are aware that the premedical years should both build
and reflect the character, but they cannot help being strategic in their advice
to students. We discovered that there is a continuum of advice giving.
Virtual
Mentor, November
2009—Vol 11 www.virtualmentor.org 860
On one
end of this continuum is the strategic—“you
must do this to satisfy the admission committee”—and on the other
end there is advice on creating character—“do
this to develop the kind of character that will make a good physician.”
Fine gradations in language
distinguish advice on “how to build one’s character” from the
more instrumental “how to impress an admissions committee.”
For example, the University of
Virginia tells premeds that doing research will “demonstrate in-depth,
sustained scholarly exploration, as well as the presence of lifelong learning
skills that are essential in these professions” (emphasis added) [9].
Notice that premeds are not told that research will develop these qualities;
rather, the advice is geared toward the strategic goal of demonstrating
character. Similarly, premeds at Iowa State are told of the strategic value of
extracurricular activities,
Extracurricular activities that focus
on leadership and community service have become very important for admission, especially to medical school.
Get involved [10].
Advice about the value of volunteer work
is much the same. At Wittenburg College, advisors suggest that volunteering 2
to 3 hours each week during the semester demonstrates to the schools your
loyalty and commitment to the profession. Premeds at Swarthmore are told:
If you volunteer either during the
school year or the summer in health care related facilities, it shows you are
motivated and committed to helping people. It also demonstrates to medical
school admissions committees that you have seen firsthand what a medical
setting is like [11].
The emphasis is on the
strategic—medical school applicants must show or demonstrate their
character.
Conversations with premedical
students and premedical advisors reveal a disconnect between the views of these
two groups toward the premedical years. In the eyes of the advisors, the path
to medical school is best described as a journey, the demands of which help
students discover their fit with a career in medicine or with the
characteristics of different medical schools. Students have a different view,
seeing the experience more as a competition than a journey. For them, the time
is not a voyage of self-discovery but a set of obstacles to overcome on the way
to the elusive goal of medical school admission. Taking their cue from the
strategic advice they have been given, they carefully plan their undergraduate
years—avoiding classes that might have been helpful to a future physician
but might harm their GPA, calculating which clinical and research experiences
will look good on their application, and cultivating relationships with
professors with the sole purpose of obtaining positive letters of reference.
The American Association of Medical
Colleges (AAMC) has recognized that something is amiss in premedical education.
Their 2009 report, “Scientific Foundations for Future Physicians,”
describes the need for change:
www.virtualmentor.org Virtual Mentor, November 2009—Vol 11
861
This
report stems largely from the concern that premedical course requirements have
been static for decades and may not accurately reflect the essential
competencies every entering medical student must have mastered, today and in
the future [8].
The report goes on to note the value
of a broad, liberal arts education for the nation’s future doctors:
The work of the committee is based on
the premise that the undergraduate years are not and should not be aimed at
students preparing for professional school. Instead, the undergraduate years
should be devoted to creative engagement in the elements of a broad,
intellectually expansive liberal arts education. Therefore, the time commitment
for achieving required scientific competencies should not be so burdensome that
the medical school candidate would be limited to the study of science with
little time available to pursue other academically challenging scholarly
avenues that are also the foundation of intellectual growth [8].
But, curiously, the report focuses
exclusively on the natural sciences, describing eight competencies, all in the
natural and physical sciences, that should be acquired in medical school, and
eight competencies, again, all in the natural and physical sciences, required
of those who enter medical school.
Those who are concerned about the
character of our nation’s physicians—about their ability to reason
morally, to diagnose by listening to patient stories, and to care about
patient’s lives and not just their cells and organs—must think
deeply about the way students land on the doorstep of medical school. When we
use the winnowing fork of GPA and MCAT scores, are we separating the wheat from
the chaff? Does the premedical experience create medical students with the
skills to become healers?
On the basis of our research and
observations, we suggest a new approach to premedical education—an
approach that not only provides the nuts and bolts of recommended coursework
and necessary preparation for the MCAT, but that also gives students the
opportunity to step back and reflect on the path to a career in health care.
Students must realize that the undergraduate premedical experience is not just
a means to enter medical school; it is also an experience that is shaping
character. The best way to help premeds understand the influence of the hidden
curriculum is not another class on ethics or professionalism. What is needed is
a course that encourages students, early in their premedical careers, to
reflect on their motives for choosing to become a physician, to recognize the
influence of the premedical culture on their behavior, and to understand the
difference between the demonstration and the development of character [1].
References
1.
Gross JP, Mommaerts CD, Earl D, De Vries RG. After a century of criticizing
premedical education, are we missing the point? Acad Med. 2008:83(5):516-520.
Virtual
Mentor, November
2009—Vol 11 www.virtualmentor.org 862
2.
Flexner A. Medical Education in the United
States and Canada: A Report to the Carnegie Foundation for the Advancement of
Teaching. Bulletin No. 4. Boston, MA: Updyke; 1910.
3.
Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years
after the Flexner Report. N Engl J Med.
2006:355(13):1339-1344.
4.
Thomas L. The medusa and the snail. N Engl J
Med. 1977:296(19):1104.
5.
Wold SG. I can’t afford a B. N Engl J
Med. 1978:299(17):949-950.
6.
Gellhorn A. Letter: premedical curriculum. J
Med Educ. 1976:51(7 Pt 1):616-617.
7.
Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA. 2006:296(9):1128-1131.
8.
Association of American Medical Colleges. Scientific foundations for future
physicians. 2009.
https://services.aamc.org/publications/showfile.cfm?file=version132.pdf&prd_id=262&prv_id=321&pdf_id=132.
Accessed October 8, 2009.
9.
University of Virginia. University career services. 2009.
http://www.career.virginia.edu/students/preprof/prehealth/extra.php. Accessed
October 8, 2009.
10.
Iowa State University. Preparation for pre-health professions. 2009.
http://www.las.iastate.edu/academics/prehealth/preparing.shtml. Accessed October
9, 2009.
11.
Swarthmore College. Pre-med advising. http://www.swarthmore.edu/x8886.xml.
Accessed October 8, 2009.
Raymond G. De Vries, PhD, is a
professor in the bioethics program in the Department of Obstetrics and
Gynecology and the Department of Medical Education at the University of
Michigan Medical School in Ann Arbor. He is the author of A Pleasing Birth: Midwifery and Maternity Care in the
Netherlands and coeditor of The
View from Here: Bioethics and the Social Sciences. In addition to
his research on premedical education, Dr. De Vries is writing a critical social
history of bioethics and is studying the regulation of science; international
research ethics; the difficulties of informed consent; bioethics and the
problem of suffering; and the social, ethical, and policy issues associated
with non-medically indicated surgical birth.
Jeffrey Gross is a first-year medical
student at the Northwestern University Feinberg School of Medicine in Chicago.
The viewpoints
expressed on this site are those of the authors and do not necessarily reflect
the views and policies of the AMA.
Copyright 2009 American Medical
Association. All rights reserved.
www.virtualmentor.org Virtual
Mentor, November 2009—Vol 11 863
Please see our website http://www.hunter.cuny.edu/studentservices/prehealth/postba
for further information. We would be happy to answer other
questions via email. Information sessions regarding the postbaccalaureate
certificate program are offered through Hunter's Office of Admissions in their
Welcome Center. Please see our website for upcoming sessions.
Mrs.Wood-Hill
Director, Prehealth Professions Advising Programs
Hunter College of CUNY
695 Park Ave, E812
NY, NY 10065
212-772-5121
FAX: 212-772-5138
http://studentservices.hunter.cuny.edu/prehealth.htm
Join the premedinfo-L listserv!http://hunter.listserv.cuny.edu