Eaglen, Robert H. PhD; Arnold, Louise PhD; Girotti, Jorge A. PhD; Cosgrove, Ellen M. MD; Green, Marianne M. MD; Kollisch, Donald O. MD; McBeth, Dani L. PhD; Penn, Mark A. MD; Tracy, Sarah W. PhD
Several recent commentaries1–3 have suggested fundamental drawbacks in the baccalaureate education of medical students. Challenges include the stress of competition in traditional premedical environments and its negative impact on the attributes of medical school applicants,1–3 the narrow scope of admission tests that pay scant heed to ethics and behavioral science,4 conventional premedical curricula disconnected from the scientific foundations and associated competencies expected of future physicians,5 and inefficiencies in the preparation of physicians, notably a protracted education that exacerbates burgeoning costs and invites unwanted redundancy.6
Whereas select committees and panels have convened to recommend solutions to these problems,4–7 combined baccalaureate–MD degree programs (which we define in the next section, and hereafter refer to as “combined programs”) have long addressed these and other issues in preparing future physicians.8 The varied ways in which combined programs have approached these challenges over the last half century merit further attention and study to determine whether they have indeed developed solutions to these vexing problems.
Combined programs first appeared in U.S. medical schools in 1961 at Northwestern University Medical School (now the Northwestern University Feinberg School of Medicine) and Boston University School of Medicine and have increased steadily in number since then. By 1992, the number had grown to 34 programs; by 2000, to 53 programs.9 By our most recent counts in 2011, there were 81 distinct programs, available at 57U.S. medical schools.
There were several reasons for the initial development of combined programs in the early 1960s, including a declining applicant pool in which “the brightest of college students entered fields other than medicine where they would encounter exciting and challenging courses of study.”8 An increased emphasis on scientific research during that period provided further stimulus for the creation of interdigitated premedical and medical course work that would attract talented students for a new era of medical practice. Later in the decade, physician shortages led to national policy initiatives aimed at graduating more physicians in less time, especially in primary care practice targeted at medically underserved areas.9
Current combined programs commonly offer conditionally guaranteed medical school admission, which may reduce competitive pressures during the baccalaureate phase and so mitigate “premed syndrome” among medical school applicants. A leitmotif of some programs has been “to render the baccalaureate preparation of physicians more stimulating yet humanistic.”8 Such programs emphasize humanities and liberal arts as a counterbalance to the science and math focus of traditional premedical programs. Some programs offer accelerated curricula that reduce total program duration, may lower overall educational costs to students, and provide a more rapid transition to income-generating careers.
Recognizing the potential of combined programs to address the issues noted above, an informal consortium of these programs has developed a comprehensive inventory to update previous reviews of the programs8,9 and, more important, to ensure that future research designs employ appropriate comparisons. Using the consortium’s data, in this article we describe the number, geographic distribution, and institutional affiliations of current programs, their missions and goals, curricula, admission and retention requirements, duration, and size. We conclude with suggestions for future studies on the value of combined programs as alternatives to the traditional premedical admission pathway.
Defining and Identifying Combined Baccalaureate–MD Programs
The broad diversity of combined programs makes them difficult to define precisely. An earlier review defined such a program as “an integrated educational experience involving an undergraduate college, which usually awards the baccalaureate degree, and a medical school, which awards the MD degree.”9 The essence of that definition is the concept of an integrated educational experience. Although all of the programs mentioned in this article award baccalaureate and medical degrees, the extent of integration between baccalaureate and medical learning experiences is exceedingly difficult to extrapolate from program descriptions.10 To circumvent that problem, we define a combined baccalaureate–MD program as a program of study that
1. is open to program applicants at the high school or early college levels;
2. includes one or more years of course work at the baccalaureate level in addition to a complete medical school curriculum;
3. provides medically related learning experiences during the baccalaureate phase of the program; and
4. offers either a conditional guarantee of medical school admission linked to satisfactory academic progress during the baccalaureate phase, or a high likelihood of medical school admission on satisfactory completion of the baccalaureate phase.
To identify combined programs, we consulted several sources, including Medical School Admissions Requirements (MSAR) 2011–2012,11 published by the Association of American Medical Colleges (AAMC). We also consulted a list of programs taken from curriculum directory information posted on the AAMC Web site as of September 201012 (no longer available) and on individual Web sites of all fully accredited U.S. MD-granting medical schools as of March 2011. Because nomenclature can be misleading, we reviewed all programs labeled “combined baccalaureate–MD” to ascertain whether they indeed met our definition. We also examined programs called “early assurance” and excluded those that did not fit our description, particularly those that did not incorporate medically related learning activities into the baccalaureate curriculum—a characteristic that combined programs emphasize. We excluded “early decision” programs that offer early acceptances within the normal admissions cycle for traditional premedical students. Identification of the programs began in 2009 and was continuously updated through spring 2011.
A single medical school may offer multiple combined programs, often in collaboration with different baccalaureate institutions. In the descriptions that follow, we count each of these programs separately. Appendix 1 lists all programs we identified that conformed to the definition described above, and includes some of their key characteristics. The information presented in the Appendix represents our considered judgments but should not be construed as a definitive list or characterization of all programs that might be considered combined programs.
Number, Geographical Distribution, and Institutional Affiliations of Combined Baccalaureate–MD Programs
Our search yielded 81 active combined programs at 57U.S. medical schools as of March 2011. Among those programs, 64 (79%) were open only to high school seniors, whereas 14 (17%) considered only applicants already enrolled in a college or university, most commonly at the end of their first or second year of study. Three programs (4%) accepted students from either high school or college. Whereas most programs for high school students tendered a conditional offer of medical school admission as part of the admission offer for the program, three deferred medical school admission decisions until the second or third year of baccalaureate study.
We found combined programs in all geographic regions of the country as defined by the AAMC Group on Educational Affairs.13 However, they were proportionally scarcest in the Western region, where 5 of the 16 medical schools (31%) offered baccalaureate–MD programs. Eighteen (50%) of the 36 medical schools in the Northeast region and 22 (51%) of the 43 schools in the Southern region offered such programs, whereas 12 (41%) of the Central region’s 29 medical schools sponsored combined programs.
Combined programs were slightly more common among community-based medical schools than among research-intensive medical schools. Seven (39%) of the 18 fully accredited community-based medical schools identified in the AAMC’s Medical School Profile System (MSPS)14 offered one or more combined programs. Thirteen (33%) of the top 40 research schools listed in the MSPS offered such a program.
Missions, Goals, and Purposes
Although the health care environment has changed dramatically since the early era of combined programs, many of the underlying pressures of that time continue to be reflected in the missions, goals, and purposes of such programs today. We collected data on missions, goals, and purposes from the Web sites for the 81 current combined programs and classified them into the categories listed in Table 1. When Web site information was ambiguous, we made telephone inquiries to assess the program’s raison d’etre. The table summarizes the number of programs with missions or goals within each category. Some goals are interrelated; for example, programs that emphasize recruitment of minority or disadvantaged students may also have a mission to address local workforce needs for primary care physicians or to focus on care for the medically underserved. The table accounts for all stated program goals whether they are related or not.
One of the original stimuli for combined-degree programs in the 1960s—attracting academically talented students—emerged as the most frequently stated purpose of present-day programs. In the early years, this was more of a driving force for the medical schools than for their partner baccalaureate institutions, but the reverse circumstance is more common now, as competition increasingly drives baccalaureate-degree-granting institutions to enhance the academic profile of their student body. Like several combined-degree programs that began in the 1970s,8 many of today’s programs seek students from underrepresented or disadvantaged backgrounds and focus on rural or urban populations, anticipating that such students will eventually practice in those settings.15–17
Current programs employ varied strategies to decrease competitive pressures: eliminating the MCAT requirement, offering provisional guarantees of admission to medical school, abolishing the medical school application, and developing additional mentoring opportunities for students. Sixteen (80%) of the 20 programs that explicitly aim to reduce competitive pressures also had a mission to recruit honors students or students from minority or disadvantaged backgrounds. Surprising to us, only 9 programs (11%) had the explicit goal of providing early clinical experiences, even though clinical experience was required or strongly encouraged in almost all programs.
For 23 programs (28%), decreasing total program length was an explicit or potential option, but in only 3 instances was it the only goal. As remarked earlier, shortening the duration of combined programs may in principle lessen the total financial impact of baccalaureate and medical school education, if for no other reason than transitioning graduates to income-earning years more rapidly; however, only two programs linked those two goals explicitly. Formal strategies to lessen educational indebtedness include merit-based scholarships for applicants who are honors students, targeted underrepresented minorities, or rural students who commit to practicing primary care in their underserved home regions. How such strategies might intersect with shortened program duration to lessen the economic burden of professional education will be an important area for future research.
Thirty-one programs (38%) had adopted one or more missions reflecting needs of society or of the medical profession. Programs explicitly addressing regional and national physician shortages frequently targeted underserved populations, in varied ways. The SUNY Upstate Medical University College of Medicine, for example, offered five distinct programs oriented toward rural care, each affiliated with a different undergraduate institution. The University of New Mexico School of Medicine also focuses specifically on rural care and care for the underserved, while targeting underrepresented minority students.17 The Sophie Davis School of Biomedical Education seeks inner-city students who will practice primary care in urban settings.15,16 Fourteen (45%) of the 31 programs with societal missions also seek underrepresented minorities as a recruitment goal. Other special populations targeted by combined programs are potential scientists and engineers, specialists in health care policy, and students with a passion for the humanities.
Characteristics of Combined Baccalaureate–MD Programs
Some information reported in this section comes from the 2011–2012 edition of the MSAR11 and from medical school Web sites. Because the information and the levels of detail from these sources are highly variable and more qualitative than quantitative, two of us sent a comprehensive questionnaire in January 2010 to the 57 medical schools offering a combined program. The questionnaire was available in both electronic and print formats and was declared exempt from review by the institutional review board at the institution of the primary questionnaire developer (J.G.). Responses to survey items yielded additional information about each program’s duration, size, admission criteria, curriculum, and retention requirements. Ethical approval for the use of a questionnaire about the organization and function of combined programs was waived by the institutional review board for the principal developer of that questionnaire.
Thirty-one schools representing 39 programs responded. The survey results reported below convey the variety of ways in which these combined programs were organized and functioned at the time of the survey. We caution that the numerical summarizations of that survey are not necessarily representative of combined programs as a whole.
In all combined programs, the duration of the medical phase is four years. Thus, variations in overall program length reflect the duration of the baccalaureate phase. Because some programs do not begin until students have completed one or more years of baccalaureate study, we only report here the total program length (baccalaureate plus medical) for the 67 programs that accepted high school seniors. Fifty-three (79%) of those programs were eight academic years in length. Four (8%) of the eight-year programs offered the option of finishing in seven years.
Only nine programs (13%) were seven years long, and five (7%) were six years in length. These shorter programs reduced their length by compressing the baccalaureate component in any of several ways: granting baccalaureate course credit for medical school course work, reducing the total number of credit hours required for the baccalaureate degree, or using summer session courses to compress four years of study into three academic years. Some medical schools currently offer different programs of varying durations. At Albany Medical College, for example, the Accelerated Physician–Scientist Program is seven years in length, whereas the Leadership in Medicine Program and the Science, Humanities and Medicine programs are each eight years long.
Combined programs typically enrolled a small number of students. Twelve (39%) of the 31 schools responding to our survey admitted 10 or fewer students each year, and 14 (45%) enrolled less than 10% of their first-year class from the ranks of baccalaureate–MD students. Of the 22 schools where we obtained enrollment information from other sources, 9 (41%) admitted 10 or fewer students, whereas none of the other 13 schools accepted more than 26 students per year. However, some programs were quite large. Four schools in the survey (13%) admitted more than 50 baccalaureate–MD students per year, and, in 3 of these (University of Missouri–Kansas City School of Medicine [UMKC], Northeast Ohio Medical University College of Medicine, and Sophie Davis School of Biomedical Education of the City University of New York), seats reserved for students from the combined program constituted 90% or more of the first-year medical class. The curricular length of these 3 large programs was six or seven years, thus skewing the overall output of combined programs toward younger graduates.
According to our survey, the kinds of criteria that combined programs used to make admissions decisions mirrored those used for traditional medical school admissions. These included a mix of quantitative data (overall and/or science and math grade point averages; ACT or SAT scores) and qualitative judgments (e.g., expressed interest in medicine, involvement in extracurricular activities, volunteer experience in health care settings).
Nineteen (49%) of the programs at schools responding to the survey offered either a bachelor of science or a bachelor of arts degree. Sixteen programs (41%) offered only the bachelor of science degree, and the remaining four (10%) offered only the bachelor of arts degree.
In general, the distinctive curricular elements of combined programs occurred in the baccalaureate phase, as part of the platform to prepare students for the next stage of their education. One notable exception was the program at UMKC, where baccalaureate-level course work runs throughout the entire six-year program, with a progressively increasing ratio of medical course work to baccalaureate study as students advance through the program.18 Another exception was the program at the Sophie Davis School of Biomedical Education,15,16 which operates similarly to UMKC through the first two years of MD study; it differs from UMKC insofar as Sophie Davis students transfer to other medical schools for the final two years of MD degree work.
The most common program-related curricular elements reported in the survey were honors seminars and special courses tailored for baccalaureate–MD students during the premedical phase of the program. Depending on the mission and focus of an individual program, special courses emphasized science, social sciences, or humanities topics. In 12 (31%) of the programs described in the responses to our survey, the instructors for those or other courses in the baccalaureate phase were members of the medical school faculty. Participation of faculty members from baccalaureate-degree-granting institutions in medical course work was much less frequent, with only 4 programs (10%) reporting such activity.
In 31 (79%) of the programs at schools responding to the survey, formal course work related to the baccalaureate–MD program was reinforced by extracurricular activities that were required or strongly encouraged. Extracurricular activities entailed community service or some type of clinical experience but could also take other forms such as research or field work. Fifteen programs (38%) also provided learning communities to support and embellish the learning experiences that take place in the baccalaureate phase. Program-specific student advising and/or mentoring were reported in all programs.
All programs described in response to our survey have established thresholds of performance during the baccalaureate phase for students to progress in the program and preserve their medical school admission offer. Minimum cumulative and science grade point average requirements between 3.25 and 3.5 on a 4-point scale were reported by two-thirds of survey respondents. Twenty-four (62%) of the programs described in responses to the survey described their MCAT policies. Of those programs, 4 (17%) did not require the examination, 6 (25%) simply required students to sit for the exam, and 14 (58%) adopted a specified minimum score. The minimum total score requirement for the MCAT varied from 22 to 31, with the lower thresholds being more common in accelerated programs, where students were likely to have less course work in MCAT-related subjects than traditional premed applicants.
Summary and Discussion
Although combined baccalaureate–MD degree programs have existed for half a century, they have seldom been prominent in discussions of medical education. This low visibility is more likely related to their small enrollment than to their frequency, as nearly half of all fully accredited MD-granting schools offer these programs now.
Today’s programs serve a wide range of purposes by reaching out to highly capable students, mostly high school seniors, who come from a variety of backgrounds in the humanities and sciences, from groups underrepresented in medicine, and from rural and inner-city urban areas. Nineteen of the 81 programs (23%) have a goal of training primary care and community practitioners, meeting the needs of underserved rural and urban populations, or both. Forty-three programs (53%) endeavor to improve the educational environment by decreasing competitive pressures, providing strong support services, integrating the liberal arts with the biomedical and medical sciences, and/or including clinical or research experience as a prelude to the medical phase of education. In so doing, many of these programs aspire to support students by integrating and enriching their curricular and cocurricular experiences while holding them to achievement standards predictive of medical school success.
The length of today’s programs represents a notable shift from program length in the early 1990s. Thirteen (42%) of the 31 programs described at that time were eight years long, 10 (32%) were seven years long, and 7 (23%) were six years long (one program could be completed in either seven or eight years).9 Today, 80% of the 67 programs that admit high school students have adopted an eight-year model. This change might counter any concern that baccalaureate–MD students are immature because of their youthfulness—an assertion ripe for future study (although it should be remembered that graduates of shorter programs have performed successfully).8 An important related topic needing more rigorous examination is the precise cost and economic benefit (to students) of combined programs, not only for the shorter programs with potentially lower baccalaureate tuition costs but also for eight-year programs that offer additional scholarship support for their students.
The notable increase in the number of combined programs through the years offers an opportunity to explore the value that these programs add to the institutions that have adopted them, to the students themselves, and to the preparation of physicians. These programs may allow medical schools to respond to local and national pressures to address physician workforce needs, for example, without committing an entire institution’s resources to that particular mission. The ongoing reflection of national needs in programs’ missions and goals through the years suggests this possibility. Earlier studies8,10 show that (1) these programs attracted and retained desirable students who might otherwise enroll elsewhere—especially honors students and students from racial or ethnic minorities, rural origins, or educationally disadvantaged backgrounds, (2) attrition rates were lower than those reported for traditional premed programs, (3) students expressed strong satisfaction with their experiences and experienced less dysfunctional stress compared with peers in traditional programs, and (4) programs focused on graduating physicians for careers in primary care orin underserved areas typically achieved these aims. Additional studies are needed to document more clearly the contributions that current programs make to their institutions, students, andthe profession of medicine. A few recent articles18–20 have discussed outcomes of combined programs, but additional documentation of program outcomes and successes is clearly needed. Of special interest would be an exploration of the extent to which baccalaureate–MD programs produce graduates with skills or abilities that clearly distinguish them from traditional premed students, in relation to the service, scholarship, and educational missions of the medical profession.
Looking Ahead: Opportunities and Challenges for Combined Programs
In an era of medical school expansion and rapidly increasing medical student enrollment, competition for well-qualified applicants with a passion for medicine has become increasingly intense. Combined programs target an applicant pool (high school and early college students) that has for the most part not been pursued by medical schools and, therefore, provide a distinctive opportunity to broaden and diversify the base of potential future physicians. Data from the AAMC Matriculating Student Questionnaire21 consistently indicate that nearly half of all medical students make the decision to pursue a career in medicine before or during their high school years. In the period from 2004 to 2011, the percentage of new medical students who definitely decided before college that they wanted to study medicine fluctuated between 47.2% and 52.8%.21 By reaching out to this applicant pool and offering them the opportunity to channel and apply their interest in medicine during their college years, combined programs uniquely capitalize on that early commitment to the profession and can help to ensure that the passion for medicine is sustained during the formative college years.
As presently constituted, combined programs also pose some interesting challenges. They tend to be small in size and varied in their organization and purpose, making generalizations difficult. Identifying potential students who possess appropriate personal and emotional characteristics for the profession is particularly challenging when the applicants have not matured emotionally or socially to the same extent as college seniors. For those programs that strive to reduce competitive pressures or emphasize humanistic qualities, there have been no studies to date indicating whether students in those programs are different in any meaningful way by the time they begin medical school, or whether any such differences persist after the students merge with students who enter via the traditional premed pathway.
The integrated educational experiences intrinsic to combined programs allow medical schools to cultivate specific career interests that address local or national needs, such as a focus on primary care medicine or medical research, by providing relevant experiences and mentoring opportunities during the baccalaureate years. Although we believe that these programs are successful in addressing regional or national needs, we acknowledge that comparative outcomes studies have been sparse, and our data clearly indicate that such studies need to account for variations in program goals, size, and organization. Our expectation is that the information we have provided here will facilitate appropriate comparisons and ensure that outcome studies are properly designed.
We have presented an overview of current baccalaureate–MD programs, established a foundation for posing important research questions, and offered a framework for developing rigorous multi-institutional methodologies to answer these questions via testable hypotheses. Each program represents a unique laboratory where the baccalaureate experience can be tailored to address specific medical school goals for a carefully selected type of student. Notwithstanding the distinctiveness of each program, our review and personal experiences with these programs reaffirm the assertion in a 2000 study that “a carefully chosen group of high school students can achieve high academic standards in a combined-degree program, graduate as younger physicians able to perform well in postgraduate training, and have highly productive careers in medicine.”8
Acknowledgments: The authors express their gratitude to the Group on Combined Baccalaureate–MD Programs, whose organization has made possible the meeting of minds that culminated in this article and the germinal ideas for future studies of combined baccalaureate–MD programs. Among the members of that group, Nancy Galster, Flavia Nobay, MD, and Erin Quinn, PhD, deserve special mention for their helpful contributions and feedback about many of the broad issues addressed in this article as well as their input during various stages of manuscript preparation. The authors also thank the anonymous reviewers and editorial staff whose thoughtful insights and helpful suggestions greatly improved the content and clarity of this work.
Other disclosures: None.
Ethical approval: Ethical approval for the use of a questionnaire about the organization and function of combined baccalaureate–MD programs was waived by the institutional review board for the principal developer of that questionnaire.