RIFKIN, MARY R.; SMITH, KENNETH D.; STIMMEL, BARRY D.; STAGNARO-GREEN, ALEX; KASE, NATHAN G.
In 1984 the AAMC report of the Panel on the General Professional Education of the Physician1 recommended that students preparing for medical school should strive for a curriculum that provides a broad study in both the sciences and the humanities and that required courses should be kept to a minimum. One way to encourage premedical students to follow a truly broad liberal arts education would be to accept students to medical school early in their college careers, thereby alleviating the pressure to focus excessively on the traditional science-based curriculum. Because there is no evidence to suggest that science majors are necessarily more qualified for medical school, we initiated an experimental program that encouraged humanities and social science majors to pursue their individual interests in college and to obtain a broad, maturing, liberal arts education. Such students might be expected to be less focused on the technology of medicine, bring different perspectives to the practice of medicine, and simultaneously diversify the student body.
In 1989 the Mount Sinai School of Medicine (MSSM) started the Humanities and Medicine (H&M) Program, an early-assurance-of-admission program designed for humanities and social science majors at a targeted group of five liberal arts colleges and universities (Amherst, Brandeis, Princeton, Wesleyan, and Williams).2 Students in this program are selected during the first semester of their sophomore year in college. Admission into the program is based on a written application with personal essays, verbal and math SAT scores, high school and college transcripts, letters of recommendation, and personal interviews. The students are required to major in the humanities or social sciences and are required to complete only one year of college biology and one year of college chemistry with a grade of B or better.
Admission to MSSM is contingent upon successful completion of undergraduate studies, provided the GPA does not drop below a minimum of 3.0. MCAT scores are not required. In addition, students are required to spend an eight-week summer term at Mount Sinai after their junior year, during which they are exposed to clinical activities and complete a much abbreviated course on the principles of organic chemistry and physics relevant to medicine. Housing and a stipend are provided. Students admitted to the H&M program are under no obligation to attend Mount Sinai should their career choices change or another medical school appear more attractive. Also, the students have the option of deferring their admission to medical school for one year after obtaining the undergraduate degree.
This study reports the outcomes of ten years' experience with the H&M Program. Our experience shows that although students in this program have more academic difficulties in the preclinical years, they excel in the clinical/community setting and have greatly enriched the medical school environment. This program demonstrates that success in medical school does not depend on a traditional premed science curriculum.
The achievements of all H&M students (n = 85) matriculating at MSSM between 1991 and 1997 have been compared with those of two matched cohorts of students who had been accepted through the standard admission process and had completed all standard premed science requirements. Students in each cohort were matched to the H&M students on the basis of year of matriculation, gender, age (within three years), category of educational institution (top 30 liberal arts colleges or universities, taken from the 1998 US News & World Report Survey), and, when possible, ethnicity, and were either humanities/social science majors or science majors. The groups of 85 students included students at different stages of their medical school careers and five classes of graduates (1995–1999).
For each group, academic performance in medical school in both basic science courses and clinical clerkships and performance on the USMLE Step 1 examination were analyzed. In addition to these quantitative indicators of performance, we performed an analysis of the students' overall medical school achievements and contributions to the medical school environment in terms of extracurricular activities, student leadership, and service, by evaluating their election to AOA and receipt of special awards. P values were determined using the χ2 test.
The undergraduate science/math background of students entering MSSM through the H&M program consists of one year each of biology and chemistry and a short summer course at MSSM, “Physics and Organic Chemistry Relevant to Medicine.” This differs from the premed science/math requirements for all other students matriculating at MSSM, namely one year each of biology, chemistry, organic chemistry, physics, and math. The data in Table 1 show that a significantly higher proportion of H&M students had at least one course failure in the basic science years than did the students with traditional premed science backgrounds, who were either humanities majors or science majors. Over 75% of the course failures of H&M students occurred in the first semester of year one, where there were nine failures in biochemistry, six in embryology, six in cell biology, and five in gross anatomy (data not shown). Among the 20 H&M students who failed one or more courses, nine students failed multiple courses, with the range being up to four courses. In the second basic science year, the proportion of H&M students with at least one course failure decreased, with no single course having a disproportionate number of failures.
Compared with their classmates, the H&M students had a higher failure rate on the USMLE Step 1 examination (Table 1), although all these students eventually passed it (data not shown). In an attempt to determine whether failure on the Step 1 examination could be predicted from data available at the time of acceptance into the H&M program, we analyzed the correlation of these students' SAT scores with their performances on the Step 1 examination. Neither Verbal SAT (R2 = 0.08) nor Math SAT (R2 = 0.07) scores correlated with the Step 1 examination score. However, all students who failed the Step 1 examination had Verbal SAT scores ≤ 650.
In the clinical years of medical school, statistically significant differences in performance between the H&M students, when compared with the matched cohorts, were less evident. The failure rate of H&M students in clinical clerkships (Table 1), the garnering of clerkship honors, and election to AOA (Table 2) were not significantly different from those of either matched humanities majors or matched science majors. In fact, the H&M students with multiple clerkship honors were often the same students who had had academic difficulty in the basic science years or who had failed the Step 1 examination. Analysis of specific clerkships indicated that the H&M students excelled in the psychiatry and pediatrics clerkships (data not shown).
In the preclinical years, Book Awards are given to those students who have performed outstanding extracurricular activity within the community or who have contributed time and energy in service to the institution. Over half the Book Awards were awarded to H&M students (Table 2). H&M students are also disproportionately represented on various subcommittees of the Student Council and other institutional committees, as well as serving in large numbers as student group representatives to national organizations such as the American Medical Student Association, American Medical Women's Association (AMWA), and Students for Equal Opportunity in Medicine (SEOM). Furthermore, a greater proportion of H&M students than students in the two matched cohorts received prizes and awards at graduation (Table 2).
Additional data, not shown, indicate that the H&M students completed medical school at the same rate and did not have a higher attrition rate than students entering medical school with more traditional premed backgrounds. Analysis of residency placements indicated that 77% of the H&M students placed in university hospital-based programs, as opposed to affiliate hospital-based programs, as did 74% of the science majors cohort and 69% of the humanities majors.
The Humanities and Medicine (H&M) Program challenges the long-standing belief that there is a necessary relationship between undergraduate science preparation and the successful completion of medical school and physician excellence. Students in this program are encouraged to use their time in college to pursue in depth their individual interests in their particular majors, which must be in the humanities or social sciences. They often spend considerable time in study abroad, independent research projects in their major fields, or extracurricular activities on campus, such as creative or performing arts or journalism. These students thereby avoid premature specialization and can obtain a broad, maturing, liberal arts education.
The academic performance of H&M students at MSSM has been compared with the performances of two matched cohorts: matriculated students with the standard, required science course background who majored either in the humanities/social sciences or in science. Since the medical school basic science courses are all graded by a norm-referenced rather than criterion-referenced system, and all the other students had had at least two more years of science, including organic chemistry, it is not surprising that the H&M students had more academic difficulties in the preclinical years than did the traditional premed students. However, in the clinical years and in the community setting, the H&M students were similar to the traditional premed students in garnering clerkship honors, institutional awards and prizes, and election to AOA.
All the H&M students who failed clinical clerkships (n = 6) also had course failures in both of the basic science years, whereas none of the students in the cohort groups (n = 3) who failed clinical clerkships had course failures in both of the first two years of medical school. While the numbers are small, these data, together with other information about these students' career goals and motivation, suggest that this subset of H&M students may represent students not wholly committed to the study of medicine. There was no evidence in the undergraduate records of these students that could have predicted this pattern of failure.
Although previous reports by others3,4 indicate that there is no significant correlation between medical school performance and undergraduate major, the students in those studies had completed the required science courses of a traditional premedical undergraduate education. Our report on the performance of the H&M students, who have majored in the humanities or social sciences and who have had minimal science education in college, indicates that, as might be expected, these students have significantly more academic difficulty in the basic science years in medical school than matched classmates who have completed the traditional premedical curriculum. Moreover, we found that all H&M students who failed the USMLE Step 1 exam had verbal SAT scores equal to or less than 650. Thus, in an effort to minimize the number of students whom we might predict would have difficulty in medical school, we have decided to pay particular attention to the verbal SAT score in our admission process, as well as to scrutinize applicants' high school science and mathematics achievements with care.
The premise on which the H&M Program is based is that by eliminating the requirement for traditional premed requirements in college, students have more time to devote to their humanities majors and other pursuits and thus have time to broaden their backgrounds, which would be beneficial to their careers as physicians. These students bring to the medical school certain qualities and outlooks that positively impact the entire medical school community. They have been among the founders of various musical ensembles, theater groups, and art exhibitions, as well as members of the executive board positions of MSSM chapters of AMWA and SEOM. The first woman president of the Student Council was an H&M student. There is no doubt that the MSSM community has been enriched by the diversity of interests brought to the campus by the H&M students.
The studies reported here should lead us to reconsider the need for the traditional science courses as a prerequisite for success in medical school. Numerous published reports5,6,7 have questioned the emphasis on science knowledge in the selection of medical students and have suggested that studies in the humanities may enhance effective patient interaction and communication. By selecting highly qualified, intelligent students early in their college careers and allowing them to develop their curiosity in their chosen fields of interest, as well as involving themselves in community and extracurricular affairs, we have shown that such students successfully complete medical school and excel in clinical activities. We intend to track these students as they complete their residencies and establish their careers to be able to more fully evaluate their contributions.
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Research in Medical Education: Proceedings of the Thirty-ninth Annual Conference. October 30 - November 1, 2000. Chair: Beth Dawson. Editor: M. Brownell Anderson. Foreword by Beth Dawson, PhD.