Despite ample attention to physicians' concerns once they are in practice, little is known about the process by which the pool of premedical students is winnowed into the group that eventually applies to medical school. Given the decline in the number of applicants to medical schools over the last five years, we must determine why some undergraduates abandon their aspirations to become physicians.1,2 As the field of medicine evolves, little research has documented how such changes affect those considering careers in this area. Are potential physicians being driven away by factors that have become part of the health care delivery system rather than by factors that actually play major roles in the duties of being a physician (e.g., long hours and dealing with terminally ill patients)? Declining numbers of medical school applicants also warrant an examination of the process by which the premedical curriculum narrows the pool of medical school applicants.
This study offers preliminary data from a single small liberal arts institution, in an attempt to determine what factors originally motivated and then deterred undergraduates from pursuing the premedical curriculum. We also explored how this group of students differed from those who persevered as premedical students. Although the sampling technique and sample size severely limit our ability to generalize our findings, the data offer a starting point for those interested in the reasons for the drop in medical school applicants. In addition, we examine gender differences in motivating and anxiety-producing aspects, and discuss implications of factors that deter certain undergraduates from becoming physicians.
From November 2000 to March 2001, a convenience sample of 44 former premed students at a small, private liberal arts college in the mid-Atlantic region completed a three-page questionnaire about why they no longer planned to become physicians. An additional 53 premed students completed an anonymous two-page questionnaire about their career aspirations to become physicians. Questions were based on a review of literature that discusses both rewarding and undesirable facets of life as a physician. Students were recruited from biology and chemistry courses (that included both students who were premed as well as those who had changed their minds). Students in the biology and chemistry classes who had never considered pursuing the premedical curriculum did not complete the survey. The questionnaire included a section about how various factors had played roles in shaping the students' initial intentions to become physicians. This was followed by a section that assessed how much certain potential stressors involved in a physician's life concerned them. The questionnaire given to former premed students asked how much such stressors had contributed to the change in their career plans. Data were entered and analyzed using a standard statistical software package.
The response rate among those eligible was 100%. Former premed students were 50% men and 50% women, while 77% were upperclassmen. The premed sample was 47% men and 53% women; 60% were upperclassmen. In both groups, approximately one third had a parent in the medical field. The most common alternative career choices among the former premed students were nursing (8%), physician assistantship (8%), medical laboratory research (5%), and teaching (5%). Most (70%) felt satisfied with their changes in career plans.
What Initially Motivated the Students to Become Physicians?
The principal factors that motivated premed and former premed students, respectively, were: interest in how the body works (98% and 93%), the power to make a difference in others' lives (91% and 88%), the wish to prove one's ability to meet such a goal as becoming a physician (79% and 77%), and the intellectual challenge (77% for both groups). The motivators with the greatest difference between the two groups were being the person in charge (56% and 70%), having a parent that wanted the student to pursue medicine (47% and 59%), and medicine's money-earning potential (62% and 72%) (see Table 1).
Factors That Worried Premed Students or Deterred Former Premed Students
Premed students worried most about the demanding rigors of the premedical curriculum (90%), their ability to earn the grades necessary for admission to medical school (88%), the compatibility of being a physician with plans to have a family (74%), having to deal with patients who might die (71%), and being in debt (65%).
Former premed students had changed their career plans chiefly because of having to be in residency for many years (89%), having to be on call (85%), the realization that other attractive career options exist (81%), and issues surrounding the compatibility of a medical career with plans to have a family (72%). These worries were followed closely by two other concerns that are very much related: the demanding rigors of the premedical curriculum (69%) and low grades (68%). We asked those who indicated low grades had been a significant factor in their changes in plans to identify a course that might have been a deciding factor: 78% named organic chemistry (see Table 2).
Differences by Gender
When we categorized all the incentives and stressors by gender, 13 variables showed at least some variation (see Table 3). Among the former premed students, women were much more likely to attribute their change to the incompatibility of a physician's life with plans to have a family (95% of women versus 52% of men: p =.00). This relates to the finding that 85% of the former premed women had been discouraged by the need for a lengthy internship and residency (although 70% of former premed men also expressed such a concern). Women were also much more likely to claim that dealing with patients who might die affected their decisions to forgo the premed route (72% of women versus 37% of men: p =.02). Such women were also more apt to be deterred from medicine by the limited time available to become acquainted with patients (40% of women versus 23% of men).
In addition, more women (76%) admitted that low grades had been a deciding factor in their changes in career plans (versus 61% of men). Of those women who stated low grades had been a factor, most (88%) named organic chemistry as the single course that had affected their plans (versus 69% of men). Former premed students who acknowledged the role of their poor performances in organic chemistry were more likely to be dissatisfied with their changes in plans than were those who did not identify this course as influential (44% versus 29%). The women in this group were less likely than the men to have been initially motivated to be a physician by the belief that a physician's income would reduce spousal pressure to contribute to family earnings.
Among premed students, men were more likely to be concerned about potential allegations of malpractice (79%, versus 53% of women: p =.05) and having to be on call (62% of men and 45% of women). Men also were more likely to be motivated by their perceptions of physicians' money-earning potential (70% versus 53% of women). Women were more likely to be worried about being the person ultimately responsible for patients' welfare (67% versus 49% of men) and were more concerned about having limited time to become acquainted with patients on a social level (71% of women versus 45% of men: p =.05).
Differences by Year in School
For some variables, upperclassmen differed from lowerclassmen in the degree to which they had been deterred from continuing the premedical curriculum. Among the former premed students, upperclassmen were more likely to have been concerned about the ability to get to know patients on a social level (44% versus 0%), more worried about hassles with insurance companies (56% versus 20%), more troubled about reports of physicians' lack of job satisfaction (53% versus 10%), and more influenced to change their plans because of the ability of physicians assistants and nurse practitioners to perform many duties that physicians execute (53% versus 30%). In addition, upperclassmen were less likely to be satisfied with their changes in career plans (68% versus 80%).
This study's small sample size limited the ability to find statistically significant differences between premed and former premed students, and between men and women. Future research with a larger sample might explore why former premed students seemed more likely to have been motivated by factors external to the actual practice of medicine (e.g., power, parental expectations, making money, and prestige). Such differences, however, may reflect the need for premed students to give answers consistent with the socially desirable motivations for being a physician. The importance of factors more inherent to the practice of medicine (e.g., helping others and the intellectual rewards) was about the same for premed and former premed students.
The survey revealed certain trends consistent with women's gender role as nurturing and uncomfortable exercising top authority. Overall, more women were concerned about dealing with patients that might die, limited time to get to know patients, and pressure stemming from being the person in charge. Men, on the other hand, focused more on aspects of being a physician that had financial implications. More men were worried about being accused of malpractice, and motivated by the perceived financial benefits of a career as a physician.
Many former premed students seemed to have weighed the rigors of the profession (especially the requirement of a long residency and having to be on call) with the realization that other attractive career options are available. Evidence of premed students' anxiety and ignorance about administrative duties as a physician3 demonstrates the need for programs such as internships that allow college students to see such considerations firsthand.4
Although most may assume that low grades are the primary reason premed students alter their plans to become physicians, only 68% of the former premed students claimed low grades had had some or a great impact on their changes in career plans, a percentage lower than we expected. Perhaps some of the 32% who did not identify low grades as a factor did not want to admit to themselves (or to the researchers) that they had been unable to achieve their goals. It may have been easier to rationalize that the change in career plans was a choice based on lifestyle issues. To admit that grades have affected one's career choice reveals a lack of control, whereas placing the blame on a decision based on negative aspects of the career allows students to save face. Women were slightly more likely to admit that their grades had determined their plans.
Given that more than two thirds of those who changed their minds about their careers did so, in part, because of low grades, it is important to note what course or courses were most problematic. For most (78%), organic chemistry was implicated, particularly for women. Eighty-eight percent of women identifying low grades as influential named organic chemistry as the course that had been a turning point in their career decisions (versus 69% of men) (see Table 3). The necessity for success in organic chemistry, which has been called the “defining premedical course,”5 deserves discussion. Should this “weed-out” course play such a significant role in selecting future physicians? Very little of what is taught in organic chemistry is knowledge that physicians ever use.6 Although the same is true of calculus and physics, at least these courses are not as likely to determine who does not become a physician. Recognition of such issues led Baylor College of Medicine to eliminate its physics prerequisite.
Furthermore, neither college grades nor Medical College Admissions Test (MCAT) scores predict later success in clinical endeavors, either in third- and fourth-year medical school clinical rotations or as a practicing physician.7,8 Yet organic chemistry provides medical school admission counselors with a difficult course that will help them eliminate some of the applicants who cannot excel in this area. The need to reduce the number of applicants is understandable; however, perhaps the litmus test should be a course of more contemporary relevance such as biochemistry or molecular biology. Alternatively, elements of organic chemistry and physics could be incorporated into other premedical courses (such as biochemistry). In addition, statistics and epidemiology may be more useful to future physicians than calculus.
Because of increasing patient dissatisfaction with their relationships with their physicians,9 perhaps courses that address social skills would be more applicable to a premedical curriculum. Indeed, the humanities may serve to promote in physicians qualities such as compassion and social responsibility.10 Some evidence exists that premed students with solid backgrounds in humanities, in addition to science, have lower medical school attrition11 and no greater incidence of academic difficulties in medical school.8,9,12 The number of undergraduate science courses seems to have no impact on the performances of medical students in their preclinical years13 or later on clinical performance ratings.14 The MCAT scores, premedical science grades, and preference for scientific study do not appear to predict medical students' clinical proficiency (versus their classroom performances in the first two years of medical school). In fact, those with higher scores in these areas were found to be less capable in interpersonal relationships.15 Given the lack of connection between many courses and their direct relevance to solving medical problems, it is not surprising that the premedical grade-point average has limited effectiveness in predicting medical school performance.16 Yet, calls for revamping premedical undergraduate requirements have been virtually ignored.17,18
Although this study examined the responses from only 97 undergraduates at a small liberal arts college, it suggests that aspiring physicians were attracted to the field by the intellectually stimulating challenge and the power to help others. Most of those surveyed about their responses to the premedical curriculum were very concerned about its compatibility with having a family, being in debt, and dealing with patients who might die. Former premed students had been most deterred by anticipating years of work in residency, being on call, the incompatibility of medicine with the demands of a family, the demanding rigors of the premedical curriculum, unacceptably low grades, and the realization that other attractive career options are available.
Even though some former premed students may have been rightly derailed by apprehensions about aspects of being a physician (since it is better to realize early that the rigors of the profession are inimical to one's desired lifestyle), the fact that the majority admitted organic chemistry had played a significant role in their changes in career plans deserves discussion. Given that the premedical curriculum has not been revamped in nearly 50 years,6 it may be time to consider whether a single course that neither has relevance to being a physician nor predicts success in the field should contribute to the elimination of persons who might otherwise excel as physicians if given the chance. We should be aware that many variables influence the process of physician selection, and the “weed-out” process should reflect skills a physician actually uses. Research based on a larger, more heterogeneous sample than that used in this study is needed to address these points so central to the decline in the pool of medical school applicants and ultimately to who becomes a physician.
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