Sklar, David P. MD
This issue of Academic Medicine presents one commentary and four articles1–5 that discuss the research leading to the changes that will be made in the 2015 version of the MCAT exam (these changes are summarized in this issue’s AM Last Page6). In addition, a Perspective7 from Canada analyzes several aspects of the exam to explore whether it meets the needs of medical school admission committees in that country. Finally, a commentary8 from Australia discusses the potential contribution of writing-based assessment in light of the decision to remove the MCAT Writing Sample. Reviewing these seven contributions has given me the opportunity to reflect on premedical education and the role of the MCAT exam in assisting with the admission process.
The current revision of that test is the first since 1991. The recommendations for the revision emerged after deliberations of a distinguished panel with input from faculty, students, and groups of a variety of experts. Schwartzstein et al1 describe the review process and the recommendations that resulted. Because the content of the MCAT exam will drive much of the premedical curriculum, changes in the test to include sections on the social and behavioral sciences and critical thinking will have a major impact on the course selection and academic experiences of students preparing for medical school.
As we review the new content areas of the MCAT exam, it is also worth considering how well MCAT scores on the current version of the test have predicted future success in medical school. Dunleavy et al2 examine 2001–2004 U.S. medical school matriculants’ MCAT total scores and undergraduate grade point averages as predictors of unimpeded progress through medical school. They found that a combination of both measures was a good predictor of unimpeded progress.
In another article, Monroe et al3 compare today’s admission process with that of the mid-1980s. The authors state that “arguably, the most notable change … is the increased importance placed on nonacademic data in making acceptance decisions.” Understanding trends in the admission process is valuable in providing a context for the MCAT exam and how its scores are used. Davis et al4 examine differences in the MCAT scores of black, white, and Latino applicants to explore whether there is bias in the test. Although they did find differences in mean scores, they did not find evidence of bias in the prediction of future performance in medical school on the indicators studied. Koenig et al5 report research on the personal competencies (e.g., social and interpersonal skills) important for entering medical students’ success in medical school and discuss ways in which they could be assessed as part of the admission process. They define nine personal competencies but indicate that there is not yet a clear method for accurate assessment. I believe that, for now, interviews and examination of past achievements, while of variable reliability, will likely continue to be used by admission committees in the absence of better methods of assessment.
Taken as a whole, these articles should encourage a careful examination of the current approach to medical school admission. While the processes for reviewing the MCAT exam and the recommendations emanating from those reviews can give us confidence that many important questions were considered, those processes cannot tell us whether our current premedical education and admission practices are fostering the best future physician workforce possible. For example, what about the students who are filtered out of the current admission process because of their performance on the test? How might they have contributed to the health care system if they had been admitted to medical school? Eskander et al7 ask similarly provocative questions from a Canadian perspective to stimulate our thinking about the use of the MCAT exam.
Examining the admission process leads us to ask whether our current approach to premedical education is the right one. Students preparing for medical school pursue a curriculum that has predominantly included a concentration in the biological sciences. Over the years, critics have raised objections to this approach to the premedical curriculum. Lewis Thomas, in The Medusa and the Snail,9 called for the complete elimination of the concept of the premedical curriculum and of the distinct identity of students as “premeds.” He expressed concern about the negative impact on individuals’ development and on the educational environment. Gunderman and Kanter10 revisited the Thomas essay in this journal in 2008 and found that many of the criticisms raised by Thomas continued to exist. They agreed that the undergraduate experience was as important as medical school in developing future physicians and that a fully formed physician must have the background to reflect on the human condition. Emanuel11 argued in a similar vein in 2006 that much of the physical sciences education included in the premedical curriculum was wasteful and should be eliminated. Mount Sinai School of Medicine took up the challenge put forth by these critics and created an admission process that eliminates the MCAT exam and science requirements for a subset of humanities-oriented students. The school has found that the performance of the humanities-oriented students at medical school is similar to that of the traditionally trained students and that those students have been more likely to enter primary care.12
The MCAT exam drives much of the premedical course work, as it provides an objective comparison between students from a variety of educational programs and institutions who must master similar content to prepare for the test. This content must be included in all courses that align with MCAT areas of concentration. A question we need to ask is, Will the new MCAT exam help not only to identify those who will succeed in passing medical school courses and national board exams but also help to recruit and select a workforce that will meet the needs of our population and changing delivery system? We will need a physician workforce whose members will want to serve diverse communities in both rural and urban environments, will function as parts of interprofessional teams, and will strive to continue to learn and improve their individual skills as well as the overall quality of the health care system. Will the inclusion of social sciences and critical thinking in the MCAT exam attract and support the applications of individuals with the interests and skills to be effective in that future workforce? Will elimination of the Writing Sample lead to a de-emphasis on written communication skills and higher-level thinking and expression, as McCurry and Chiavaroli8 suggest in their commentary?
Premedical programs and the MCAT exam have multiple purposes. One is preparing and assessing students for medical school education so that we minimize the possibility that students will fail after entering medical school and the associated waste of valuable training resources. Another is to create objective criteria that will promote fairness in selecting students when the number of qualified applicants exceeds the number of positions available. However, the premedical curriculum and the MCAT exam should not discourage students who could contribute because they excel in nontraditional areas such as arts, humanities, and social sciences.
As I review previous criticisms of premedical training and the MCAT exam, I ask myself why change from our current approaches of preparing and evaluating premedical students has been so slow. Aside from the legitimate difficulties and risks inherent in changing these approaches, I suspect that our slowness reflects a lack of an overall vision of what we want the outcome of our educational process to be, compounded by the constant growth of important new scientific knowledge. Without a clear vision of our intended goals in medical education, we are likely to become mired in the many arguments to resist change.
I believe that a way forward might be to experiment with alternative approaches, as Mount Sinai has done or as some of the BA/MD programs around the country have done.13 This could be accomplished without formally changing admission policy. Sometimes change can be best achieved through the development of alternative tracks rather than a head-on confrontation with an entrenched orthodoxy. Perhaps a new examination of premedical education and the use of MCAT scores can encourage more experiments in which schools admit cohorts of students with types of excellence that are different from those found in our current premedical model. The articles in this issue of Academic Medicine should inspire us to consider not only the specific questions they addressed but the larger questions of the continuum of medical education, what we will expect from our future physicians, and how we can match these expectations with the diversity of talents and skills of those interested in careers in medicine.
David P. Sklar, MD
Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the Association of American Medical Colleges or its members.
1. Schwartzstein RM, Rosenfeld GC, Hilborn R, Oyewole SH, Mitchell K. Redesigning the MCAT exam: Balancing multiple perspectives. Acad Med. 2013;88:560–567
2. Dunleavy DM, Kroopnick MH, Dowd KW, Searcy CA, Xiaohui Z. The predictive validity of the MCAT exam in relation to academic performance through medical school: A national cohort study of 2001–2004 matriculants. Acad Med. 2013;88:666–671
3. Monroe A, Quinn E, Samuelson W, Dunleavy DM, Dowd KW. An overview of the medical school admission process and use of applicant data in decision making: What has changed since the 1980s? Acad Med. 2013;88:672–681
4. Davis D, Dorsey JK, Franks RD, Sackett PR, Searcy CA, Xiaohui Z. Do racial and ethnic group differences in performance on the MCAT exam reflect test bias? Acad Med. 2013;88:593–602
5. Koenig TW, Parrish SK, Terregino CA, Williams JP, Dunleavy DM, Volsch JM. Core personal competencies important to entering students’ success in medical school: What are they and how could they be assessed early in the admission process? Acad Med. 2013;88:603–613
6. Kroopnick M. AM Last Page: The MCAT exam: Comparing the 1991 and 2015 exams. Acad Med. 2013;88:737
7. Eskander A, Shandling M, Hanson MD. Should the MCAT exam be used for medical school admissions in Canada? Acad Med. 2013;88:572–580
8. McCurry D, Chiavaroli N. Reflections on the role of a writing test for medical school admissions. Acad Med. 2013;88:568–571
9. Thomas L. How to fix the premedical curriculum. In: The Medusa and the Snail: More Notes of a Biology Watcher. 1979 New York, NY Viking Press:137–141
10. Gunderman RB, Kanter SL. Perspective: “How to fix the premedical curriculum” revisited. Acad Med. 2008;83:1158–1161
11. Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA. 2006;296:1128–1131
12. Muller D, Kase N. Challenging traditional premedical requirements as predictors of success in medical school: The Mount Sinai School of Medicine Humanities and Medicine program. Acad Med. 2010;85:1378–1383
13. Cosgrove EM, Harrison GL, Kalishman S, et al. Addressing physician shortages in New Mexico through a combined BA/MD program. Acad Med. 2007;82:1152–1157