Gunderman, Richard B. MD, PhD; Kanter, Steven L. MD
The year 2008 marks the 30th anniversary of one of the most provocative essays on premedical education ever published. Entitled “How to Fix the Premedical Curriculum,” it was composed by then-president of Memorial Sloan-Kettering Cancer Center, Lewis Thomas, MD.1 This article reviews and then reexamines from a contemporary perspective Thomas’s three central themes: the influence of medical schools on undergraduate education, the selection of students for admission to medical school, and a radical proposed reform of premedical education. Thomas was well qualified to address these issues. A graduate of Princeton University and Harvard Medical School, he served as dean of the medical schools at New York University and Yale. In addition to his numerous scientific articles, he published many learned essays in his New England Journal of Medicine column, “Notes of a Biology Watcher.” His 1974 collection, The Lives of a Cell, won the National Book Award.2
Revisiting Thomas’s Themes
Though some thoughtful commentators question whether the “premedical syndrome”—defining the whole undergraduate experience in terms of preparation for medical school—even exists, Thomas’s “How to Fix the Premedical Curriculum” poses vital questions about both the premedical curriculum and U.S. higher education that deserve renewed attention.3 What is the purpose of undergraduate education? How closely are the undergraduate and graduate phases of medical education aligned? What do future physicians need to know that is not taught in medical school? Thomas’s essay focuses on three central topics: the influence of medical schools on undergraduate education, the selection of students for admission to medical school, and a proposed reform of premedical education.
The influence of medical schools on undergraduate education
Thomas calls the influence of medical schools on undergraduate education “baleful and malign, nothing less.” If the current approach is not reversed, he warns, we will soon “destroy all joy of going to college.” There are two principle problems with premedical education. First, the current system fosters competition for high grades, turning what should be a comprehensive meritocracy into a narrow-minded and mean-spirited “testocracy.” Each student learns to put his or her own grade point average (GPA) and Medical College Admission Test (MCAT) scores above all else. The equation is simple: GPA + MCAT = MD. Other factors, such as curiosity, intellectual stimulation, and broadened horizons, get left behind.
Second, seeing that medical school admissions requirements and the MCAT reward natural science coursework, many students focus on science, taking as few nonscience courses as they can. Thomas contrasts this with a bygone era, in which schools said they wanted students “to be as broadly educated as possible, and meant it.” As many students have expressed it over the years, “I know how to get A’s in science and math courses, so why would I take a chance on a nonrequired course in literature, philosophy, or history, in which the grading standards are less clear?” As a result, courses, courses of study, and learning itself are transformed from intrinsic ends to a means to another end—admission to medical school. This model cultivates a discouraging attitude: “I am not here to get an education. I am here to qualify for medical school.”
The selection of students for admission to medical schools
Regarding medical school admissions policies, Thomas offers a radical prescription. In Thomas’s ideal future, any applicants whose course selection distinguishes them as premed “will have their dossier placed on the third stack of three.” Moreover, membership in any form of premedical association will result in summary rejection. If a college or university offers a major in premedical studies or maintains an office of premedical advisor, its graduates will be excluded from recognition by medical schools. Such radical therapy is warranted, Thomas argues, by the fact that premedical students are “poisoning” the atmosphere of liberal arts colleges by treating their undergraduate studies as the burdensome means to attain entry to medical school.
Thomas recognizes that GPAs cannot be ignored in the admissions process, but if it were possible, he would dispense with the MCAT completely. Why? Because he deems the judgment of college faculty members a superior indicator of a student’s promise as a physician. If admissions tests must be retained, their content should be reformulated, making the natural sciences the briefest section, and the one that counts the least. In their stead, he would focus on knowledge of literature, languages, and history. One problem with such an approach is the huge diversity of students’ undergraduate backgrounds. Thomas recognizes the need for a core discipline, “universal within the curricula of all colleges,” on which all students could focus their education. This core discipline would serve as the testing ground of each student’s mind and character.
Thomas finds his preferred candidate for such a core discipline in a rather unexpected place—namely, classical studies. He argues that the centerpiece of undergraduate education should be classic Greek, the language of Homer, Sophocles, and Plato. In particular, “the capacity to read Homer’s language closely enough to sense the terrifying poetry in some of the lines could serve as a shrewd test for the qualities of mind and character needed in a physician.” No matter how high students’ science IQs, those who remained unengaged by the wrath of Achilles and the courage of Hector, the intrepidity of Odysseus and the devotion of Penelope, would lose out to those who did.
Why does Thomas want to put classics first, with “English, history, literature, at least two foreign languages, and philosophy” trailing just behind? The answer lies in what he believes medical school admissions committees need to look for and, by extension, what colleges and universities should be cultivating. Among these traits are “the free range of a student’s mind,” “tenacity and resolve,” an “innate capacity for understanding human beings,” and “affection for the human condition.” Grades, test scores, and a pure natural science curriculum do not nurture the most essential qualities of medical students and physicians.
A proposed reform of premedical education
In an address to the American Medical Association, theologian Abraham Joshua Heschel4 once said, “To heal a person, we must first become a person.” In his proposed reform of premedical education, Thomas seeks to educate future physicians first and foremost as human beings. It is human understanding at the bedside that ultimately determines how we care for patients. In medical school, interactions with patients and colleagues can foster such insight. Before medical school, the seeds of this understanding can be planted by reading great books. Courses in disciplines such as history, literature, and philosophy broaden and deepen our understanding of what it means to be human.
A highly accomplished biomedical scientist, Thomas understands the importance of science to medical practice. He knows that a physician who fails to grasp the fundamental principles of biochemistry, molecular biology, anatomy, physiology, and pathology is a physician in name only. He argues, however, that the proper time for studying such science is the years of medical school, not undergraduate studies. Although it is perfectly appropriate to study the natural sciences as an undergraduate,5 shifting too much science into college inevitably undermines a truly liberal education.
Thomas cites a number of beneficiaries of his proposed reform. First among them would be students themselves. In ridding undergraduate institutions of “that most detestable of all cliques eating away at the heart of the college,” we would be freeing undergraduates to pursue a liberal education. Students not intending to pursue careers in the biological sciences or health professions could take challenging natural science courses without fear of being crushed by hypercompetitive premeds, and aspiring physicians would be free to sample from a broad range of courses and develop intellectual interests capable of nourishing and sustaining them throughout their lives. This would stimulate the capacity to think independently and creatively, a crucial factor in their future contributions as clinicians, educators, and scientists.
Another beneficiary would be college faculties. So long as college is regarded by a substantial proportion of students, particularly the “best” students, as mere preparation for professional school, colleges cannot recapture “the destiny of their own curriculum.” We must see liberal arts courses as more than mere prerequisites. The texts, writers, and courses that comprise a good liberal arts education are not just preparation for medicine. They promote more than the practice of sound medicine. They encourage the leading of a full human life, and the reflection and conversation they stimulate represent some of the best life has to offer.
Still another beneficiary of Thomas’s proposal would be the basic science faculties of medical schools. As it is, large numbers of medical students matriculate with extensive backgrounds in the biological sciences. Some medical schools permit students to “test out” of basic science courses, and even students who do not are often less than energized by familiar material. Thomas argues that if students were discouraged from studying medical subjects before they reach medical school, basic science faculties “would again have classrooms of students ready to be startled and excited by a totally new and unfamiliar body of knowledge.” The curriculum might prove a bit more challenging, but it would also prove more engaging and enjoyable.
Perhaps the most important beneficiary would be society itself. What do we hope for in a doctor? Without doubt, we seek someone who understands the science and technology of medicine. We do not want a poet or a philosopher performing our open-heart surgery. But we also seek someone who understands, “as much as anyone can learn from our colleges and universities, how human beings have always lived out our lives.” We want someone who has developed a rich understanding of human beings and the human condition. We need to navigate difficult decisions about the goals of care, weigh potential complications, and address questions whose answers are not found in textbooks. Thomas argues that undergraduate programs should leave contemporary biomedical knowledge to medical schools and, instead, ensure that medical education is anchored in a deep understanding of our civilization.
Thomas’s Themes Today
Like any great essayist, Thomas raises more questions than he answers, inviting us to reexamine undergraduate education for ourselves. Many of his criticisms and recommendations ring as true today as they did 30 years ago. The liberal arts continue to occupy a place of special privilege in American higher education. The distinctive American educational innovation is not the research university. Great American research institutions such as Johns Hopkins University and the University of Chicago were not created de novo, but adapted from a German model. Building on the model of liberal education promulgated by such great British institutions as Oxford University and Cambridge University, the great American educational innovation is the liberal arts college. In contrast to the dominant European model, which commences professional education after high school, the American liberal arts college encourages students to spend four years relishing the fruits of human civilization.
From one point of view, devoting four years to general study might seem inefficient, even a waste of time.6 Liberal education is not free, and its rising cost adds to the mammoth debt encumbering many medical students. Especially at a time when physicians are in short supply, shouldn’t medical educators do everything possible to shorten the pipeline? Shouldn’t we simply identify the smartest students and get them into medical school at the lowest possible age? Isn’t there more than enough information to be mastered in medical textbooks? Why burden students with any information not absolutely requisite to the practice of medicine?
In fact, a purely utilitarian approach to premedical education would prove ruinous. For one thing, such a model is dehumanizing.7 Consider the education of corporate executives. If we knew that a group of students wanted to run major corporations, would we train them merely to be good readers of memos, quarterly reports, and stock quotations, and not bother their heads with poetry, science, and history?8 If such an approach would ill serve future corporate executives, how much more disastrous would it prove for physicians, whose work relies even more on a high degree of human insight, compassion, and sagacity? Good physicians need heart, and the heart, no less than the mind, requires education.
Contemporary health care resembles individual sports such as singles tennis and long-distance running less than team sports such as basketball or soccer. No matter how talented a physician might be, the quality of care we provide hinges on sharing knowledge and coordinating the efforts of multiple team members. These teams consist of physicians of varying specialties and levels of training, as well as a variety of other health professionals, such as nurses, therapists, and social workers. Future physicians need to understand that different people see situations from different perspectives, and to appreciate the vital role that organizations play in achieving medicine’s ends. These represent signature lessons of disciplines such as literature, history, psychology, and sociology.
The “liberal” in “liberal arts” derives from the same Latin root as our words liberty and liberality, meaning “free.” To perform at their best, physicians need to be educated for freedom, to think problems through for themselves, to exercise independent judgment and discretion, and to transcend an unquestioning devotion to commercialism and conformity that threatens to make doctors mere health care vendors.9 Students need to appreciate why the noblest physicians, no less than the noblest human beings, always devote their lives to larger callings. They need to understand the permanent human questions at the core of the healing arts, questions that animated the giants of medicine on whose shoulders today’s physicians are privileged to stand.
Thomas was on to something when he extolled the virtues of Attic Greek as the foundation of liberal learning. Even if students never read Homer, Sophocles, Dante, or Tolstoy in their native language, they can glean great insight from a wealth of first-rate contemporary translations. And readers of English need not necessarily repair to the ancients. To fire their hearts and minds, such learners need look no further than the plays and sonnets of Shakespeare, the poetry of Donne and the King James Bible, the satires of Swift, the novels of Eliot and Austen, and the short stories of American physician–poets William Carlos Williams and Richard Selzer, all composed in their native tongue.
The intellectual traditions of medicine whet students’ appetites for lifelong learning focused not only on the latest journal reports but also on the seminal insights of our greatest minds. When Aristotle, perhaps the single greatest mind in the history of Western civilization, first arrived in Athens, he practiced medicine. Hippocrates, Galen, and Harvey were not only physicians but master prose artists. Great poets, such as Rabelais, Oliver Goldsmith, and Chekov, were physicians, and such towering intellects as John Locke, Sigmund Freud, and William James all trained in medicine.
If we fail to develop the human insight of tomorrow’s physicians, we imperil the future of medicine.10 Students who put their own interests before everything else are more likely to become ensnared in scientific and professional misconduct. Those entering the profession with a sense of entitlement are more prone to disdain the immense trust embodied in Western medicine’s core document, the Hippocratic Oath. Those who treat their career as a business proposition will be among the first to treat their knowledge and skill as their own personal property. These habits undermine medicine as a profession, leading us to regard patients as customers and health care as a commodity.
We need to create a system that encourages students to make the kinds of choices we commend. We cannot entreat them to pursue a liberal education but place them in a system that implicitly rewards a narrow intellectual range and a superficial focus on grades and test scores.11 Encouraging students to get their stomachs in knots over fractions of a grade point is counterproductive in preparing them for the real-world practice of medicine. Competing for grades is a less valuable lesson than collaborating for human welfare. We need to encourage students to identify their own intellectual passions and pursue them in depth. We need to foster a willingness to take risks, try out new things, and be creative. We need to be good role models and mentors, expunging mixed messages and displaying the courage of our convictions.
Students matriculating in medical school need not know everything there is to know about human beings or even rank as fully mature human beings themselves. Yet, they do need to enter medicine prepared to consider the possibility that we make a life less by what we get than by what we give. Education is not about indoctrination. From the Latin for “to draw out,” education is about drawing out of students the whole person they are capable of being. Serious education is laying hands-on what is most vital in a human being.12 Medicine itself can be one of the most fertile forms of liberal education. For most of us, however, it can do so only if the soil of our intellects and characters has been properly cultivated.
We can perceive only what our mental models enable us to see and imagine. If these models have not been broadened and deepened by contact with the great poets, philosophers, and prophets of human civilization, then our outlook will be narrower and more myopic than it needs to be. If we allow economic imperatives to shape medical education to such an extent that we value physicians and even patients in dollars, and treat educating physicians as a simple matter of maximizing economic productivity, then we become accomplices in the deprofessionalization of medicine. An education is no more a commodity to be acquired than a patient is a pocket to be picked. In both cases, the more salient reality is the quest to understand and serve.
What has happened in the 30 years since Lewis Thomas first penned his prescription for fixing the premedical curriculum? We cannot say with certainty how many liberal arts courses today’s medical students have taken. Yet, we can say that of the 17,759 students who matriculated in U.S. medical schools in 2007, 8,876 (56%) had majored in the biological sciences, with another 2,291 (13%) in the physical sciences. By comparison, only 725 (4%) had majored in disciplines in the humanities.13 Of course, Thomas was not simply urging that we increase the number of humanities majors, and he understood quite well that science and the humanities are not at war with one another.14 Both have long played vital roles in preparing students for medical school.15
Thomas was making two more profound points. First, we should regard the undergraduate curriculum as no less vital to the future of medicine than medical school itself. Second, we should guide undergraduate students away from the path of premature specialization, instead encouraging them to develop as fully as possible as human beings before they enter medical training. If the physicians of tomorrow are to serve the profession of medicine, their communities, and their patients, it is vital that today’s medical students arrive having reflected broadly and deeply on what it means to be human.