The Medical College Admission Test (MCAT), originally called the Scholastic Aptitude Test for Medical Students, was created in 1928 to measure preparedness for medical school. Since that time, medical school admission has become increasingly competitive, and schools have developed detailed selection processes that use MCAT results and other variables in a number of different ways.1 Now, the fifth revision of the MCAT exam, the MCAT2015 exam, is poised to launch in 2015. Planning for this revision commenced in 2008 when the Association of American Medical Colleges appointed the MR5 advisory committee to complete an extensive consultation process for the MCAT2015 exam.2,3
Since its inception, each version of this standardized test has reflected the current understanding of the knowledge base and aptitudes required for the study of medicine. As described elsewhere in this issue,4 the MCAT2015 exam is designed to maintain successful aspects of the current MCAT exam while updating science content, enhancing assessment of scientific method, critical analysis, and reasoning, and adding a new emphasis on the behavioral and social determinants of health. These changes will broaden the value of the MCAT exam by encouraging students to seek a balanced knowledge base and work toward addressing some of the concerns around hidden curricula.5,6
Concurrently, a report entitled “The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education” was released in 2010.7 Initiated in 2007 by the Association of Faculties of Medicine of Canada, the FMEC MD project, guided by a steering committee that sought broad stakeholder input, examined Canada’s undergraduate medical education system in terms of its current and future alignment with societal needs.7–9 The report includes 10 recommendations (see List 1) to guide educational reform. These recommendations address themes including social accountability, student selection, and leadership, and share themes with other U.S. reports, reflecting common trends in medical education.9
We believe that this confluence of the FMEC MD report and the MCAT2015 revision is of singular importance warranting careful deliberations by Canadian medical schools. Canadian deliberations will be based in perspectives distinct from those of our U.S. colleagues and will reflect Canadian institutions’ differing patterns of use of the MCAT exam. In contrast to the United States, where the vast majority of medical schools use MCAT scores in admissions decisions, the use of MCAT scores in Canadian admissions is not universal but, instead, reflects schools’ differing missions, languages, and obligations to Indigenous Peoples* (see Table 1).10–14 For example, the absence of a French language test and available testing centers in Northern Canada has limited the use of the MCAT exam in certain regions.
This nonuniversal use also relates in part to Canada’s publicly funded postsecondary education system, which lacks the differentiation of the U.S. system and is more homogeneous in content and quality than the system in the United States.15–17 The overall nationwide ratio of applicants to first-year medical school seats is higher in Canada (approximately 5:1 versus 2:1 in the United States), resulting in different overall selection pressures across the two countries.18,19
Despite this nonuniversal use of MCAT scores in the Canadian admissions process, it is likely that the majority of Canadian applicants prepare for and complete the MCAT exam because most students apply simultaneously to several Canadian medical schools. Therefore, the MCAT exam broadly influences Canadian medical school admissions.
Canadian medical schools are now considering the FMEC MD recommendations, current MCAT exam use, and how the MCAT2015 exam should be used. To capture Canadian perspectives, we employ a point–counterpoint format to examine three questions regarding the FMEC MD recommendations and the MCAT2015 exam: (1) Is the MCAT exam equal and useful in Canadian admissions? (2) Does the MCAT exam affect matriculant diversity? and (3) Is the MCAT exam a strong predictor of future performance? To conclude, we offer our own perspectives on whether or not Canadian medical schools should use the MCAT2015 exam in admissions decisions.
Is the MCAT Exam Equal and Useful in Canadian Admissions?
Arguably the first obligation of admissions committees is to select the students most likely to succeed in meeting the academic requirements of medical school. A well-structured standardized examination may provide the best mechanism to assess this.
Medical school admissions committees consider multiple factors, including academic ability, personal characteristics, and skills of applicants. The academic background and standing of candidates are generally assessed through grade point average (GPA) and MCAT scores. The MCAT exam as a standardized single test provides context for interpretation of GPA data from a wide variety of undergraduate programs and institutions and assists in identifying academically capable students. Although all Canadian schools evaluate “nonacademic” criteria in admissions decisions, it has been repeatedly demonstrated that baseline academic criteria are the most reliable predictors of success in medical school, the obvious first essential step in becoming a practicing physician.20–22
In response to societal expectations and recommendations such as those of the FMEC MD report, Canadian medical schools’ prerequisite requirements seem to be shifting. This suggests that future applicants will come from increasingly diverse academic backgrounds, and their academic skills and aptitudes may not be fully comparable based on assessments of GPA alone. Although many students applying to medical school have completed science undergraduate degrees at similar universities, medical school applicants increasingly come from nontraditional arts or humanities programs, graduate-level studies, or courses at institutions in the non-research-stream, vocationally directed Canadian college sector. It is difficult to use GPA as predictor of medical school performance from these diverse backgrounds without a means of standard comparison.
The MCAT exam is a unique tool amongst those used to select the ideal medical school candidate. It has well-established metrics and predictive utility, and it is the only universal standardized tool available to admissions committees. It provides important information regarding academic aptitude, knowledge base, and critical reasoning skills, beyond what is provided by GPA and other components of applications.22,23 In its next iteration, it is designed to further enhance information provided to admissions committees, particularly in areas of knowledge not easily assessed currently, and in important skills including scientific method and critical analysis.
Without using the MCAT exam, admissions committees have little basis to compare students from diverse backgrounds. For medical schools assessing thousands of applicants competing for a limited number of spots, it seems that only the MCAT exam allows for a reliable and simple comparison of applicants in a fair and standardized fashion.
No single tool can capture the breadth of applicants’ academic and nonacademic strengths and weaknesses. Used with an admissions toolbox, as intended, the MCAT exam is a valuable and important part of admissions assessments, providing unique yet standardized information regarding applicants.
A standardized test like the MCAT exam is not imperative for Canada. Canadians consider universities (and health care) to be a public good and have established a university system with equivalent standards.17 Canada’s universities and medical schools are under provincial government jurisdiction. High school students seldom leave their home provinces for university,15 and for university students considering medical school, their likelihood of acceptance is greatest within their home provinces.12,24 The Canadian university landscape of equivalent standards and the predominant province-based path from university to medical school contrasts with the United States’ broader, nationally focused higher education landscape and lessens Canada’s imperative for a standardized test like the MCAT exam.
The FMEC MD report calls for the enhancement of medical school admissions processes. This recommendation acknowledges medical schools’ long-standing efforts to incorporate nonacademic factors into admissions processes but emphasizes that today these factors are of critical value. One response to the FMEC MD report’s admissions-related recommendation is to suggest that the primary objective of admissions committees has been transformed into a dual obligation to select applicants most likely to succeed in meeting the academic and nonacademic requirements of medical school simultaneously.
Although MCAT revision committees have long considered incorporating nonacademic factors into the exam,25–27 a range of unanswered questions regarding reliability, validity, costs, testing time, and the influence of commercial preparation services have prevented such changes thus far.27 A recent Canadian Medical Association Journal news feature highlighted the absence of nonacademic factors in the MCAT2015 exam.28 We believe that Canadian medical schools should adopt the aforementioned dual admissions obligation valuing both academic and nonacademic factors. The MCAT2015 exam will not assess nonacademic factors and will not advance this recommended dual-selection obligation.
Although the MCAT exam may be standardized for all, is it equal for all? In the United States, the test preparation industry, which includes MCAT test preparation, is a multimillion dollar industry.29 Although medical education literature does not attest to the added value of these courses,30 their use is widespread.27 This widespread use may relate to other factors relevant to applicants’ decisions regarding MCAT test preparation courses, including applicants’ examination anxiety,29,30 industry marketing,29,30 and applicants’ belief in these courses’ added value.27,31 This U.S. industry also reaches into Canada, attracting Canadian applicants to MCAT preparation courses.31 The direct course costs are significant,31 and they become even greater when factoring in indirect costs for applicants who focus on MCAT studies, not working during the MCAT preparation period.30,31 This commercialization of the application process creates a barrier for students with less economic resources and negatively affects the socioeconomic diversity of Canada’s medical students. A call for examination into financial barriers within admissions processes has been published recently in Canada.10 Canadians value universal access to health care, and this value must be extended to medical school admissions.
Does the MCAT Exam Affect Matriculant Diversity?
Medical schools across Canada are striving to increase diversity, recognizing and often explicitly stating in mission and value statements the importance of a diverse medical student body reflecting the populations they will serve. Canadian medical students are now much more broadly representative of the gender and ethno-cultural background of our diverse population than they were a generation ago.32 However, medical students tend to come from economically privileged backgrounds, and, relative to the general population, Aboriginal Peoples, as well as other groups, are significantly underrepresented among medical students.10,32 Some argue that requiring applicants to take the MCAT exam creates a barrier to successful entry for some populations.10,11,13,14 Underrepresented groups often face differences in access to testing centers and inequities in test readiness and preparation, as well as the possibility of lower average test scores, which can underpredict aptitudes and skills, resulting in lower rates of acceptance. If medical schools use MCAT scores as a comparative marker of student and medical school quality, this may increasingly disadvantage underrepresented populations.25,33,34
MCAT reports confirm that across U.S. test takers, who self-identify ethnic and racial group membership when they register for the exam, average mean scores of white test takers are higher than those for black, Hispanic, and Native American test takers.35–37 The ranges of scores are wide for all groups reported. Analogous data for Canadian test takers are not available because test takers are not required to identify ethnic and racial group membership routinely, but Canadian outcomes may be similar, as differences seen in MCAT scores parallel those seen on a variety of standardized tests.36
Assuming that Canadian outcomes are comparable to U.S. outcomes, it is important to note that data analysis and research studies assessing the predictive value of the MCAT exam do not show underestimation of subsequent medical school performance or board examinations for racial/ethnic minority groups.36,38 Information reviewed by the MR5 committee36,38 indicates that the test is robust in predicting performance in all test takers.
Extensive research has been carried out to determine the reasons for lower scores in standardized testing amongst disadvantaged populations, primarily in U.S. settings.36,39–42 A variety of applicants’ environmental and family characteristics have been shown to vary in correlation with socioeconomic and ethnic backgrounds, and some of these in combination may lead to decreased academic achievement and performance on standardized tests. Influential factors include poor neighborhood and environmental effects, the effects of differential parental participation in school, and different quality of elementary, high school, and undergraduate education. The influence of these factors is seen in the decreased scores of affected test takers on a wide variety of standardized tests used in the United States. It is likely that many, if not most, of these factors are present long before disadvantaged individuals consider applying to medical school, and they contribute to the recognized group differences in scores.
These factors and differences are present in Canadian groups such as Indigenous Peoples. If Canadian outcomes are comparable to U.S. outcomes, one could hypothesize that environmental factors lead, through similar mechanisms as those observed in U.S. contexts, to different average test scores in differing populations in Canada. This, then, implies that MCAT results should be interpreted in the context of an applicant’s overall experience and background, understanding the potential influence of these factors. These data also suggest that although test results should be understood to reflect not only individual knowledge and ability, but also a variety of societal conditions, they do predict future performance equally across all groups.
U.S. data demonstrate that underrepresented minorities, such as black students, have acceptance rates far higher than the rate that would be expected on the basis of MCAT scores alone.36 This indicates that, as currently used, MCAT scores are not a barrier to acceptance for underrepresented minority applicants.1,43 Canadian schools have the option to similarly tailor the use of MCAT information in the context of an applicant’s background and institutional diversity targets, even using MCAT data to forecast the curricular support needs of incoming classes.
It should not be assumed that eliminating the MCAT requirement will automatically broaden both applicant and matriculant diversity in Canada. The elimination of the MCAT requirement would likely result in increased emphasis on GPA as a marker of academic aptitude. Similar differences exist across groups in GPA as with MCAT scores, so using GPA as the sole academic assessment would not lessen differences between groups.36
Even if admissions processes were to be redesigned to allocate increased importance to nonacademic factors including an applicant’s background and context, there is no evidence that this would in practice increase acceptance of students from underrepresented groups. There are no data to support an assumption that these groups perform better on the nonacademic components of admissions assessments (i.e., supplementary application, reference letters, and interviews) in comparison with their performance on traditional academic components (GPA and MCAT). Nonacademic components are difficult to develop and validate, and advantaged populations may benefit more than underrepresented groups from their increased weighting. This outcome emerged in the work of the Canadian Multiple Mini-Interview Research Alliance, which looked to assess whether multiple mini-interviews (MMIs) were diversity-neutral. Within the Canadian population studied, the authors reported that MMI scores were correlated negatively with Aboriginal status.44
As previously stated, admissions committees have a dual mandate to assess academic and nonacademic factors and, so, could not reasonably eliminate the assessment of academic performance. As such, effective admissions policies rely on the appropriate use of MCAT scores with GPA, interpreted in the context of applicant background and in light of school-specific data, as part of a thoughtful holistic review of applications.45
MCAT administrators are planning to provide additional low-cost, easily available preparatory materials and increased access to exam centers to address additional concerns. At an institutional level, medical schools could also take measures such as those recently taken by the University of Toronto Faculty of Law, which provides low- and zero-cost Law School Admission Test preparation for specific applicant populations, eliminating the need for costly commercial preparation courses.46 There is no evidence that higher average MCAT scores reflect a higher-quality student body in Canada, and medical school admissions offices and undergraduate faculties should continue to advocate this understanding, as the MCAT exam is neither intended nor designed for aggregate comparison of student bodies.
Overall, there is no evidence that elimination of the MCAT requirement would automatically lead to increased student diversity. Thoughtful outreach programs can support all students in preparation for the MCAT exam, and there is evidence that MCAT scores are not a barrier to acceptance of a diverse student body. Because MCAT scores provide an equally predictive result in all populations,36 these can be useful in appropriate tailoring of curricular supports.
Although the preceding argument asserts that the MCAT exam requirement does not represent a barrier to increasing diversity, this has not been the Canadian experience. For example, the MCAT exam has been identified as a barrier for Indigenous Peoples, and multiple schools employ MCAT modifications plus recruitment and retention programs to address application barriers for Indigenous Peoples.11,13,14 Complicating this issue is the absence of MCAT testing centers in Canada’s northern territories (see Table 1), which compounds distance and financial barriers for these applicants.11 These initiatives, though implemented to address these barriers, have not been associated with sufficient increases in the representation of Indigenous Peoples amongst medical students.10,32
Nivet47 proposes a diversity operating system (DOS) model with three distinct levels for describing approaches to diversity. For DOS 1.0, diversity initiatives strive to correct historical wrongs by removing barriers for underrepresented populations, but they are not integral to institutions’ academic missions. For DOS 2.0, diversity initiatives possess increasing educational value, existing in parallel with and linked to institutions’ academic missions, yet they are not integral to these missions. For DOS 3.0, diversity initiatives speak to inclusion and are core to institutions’ academic missions with diversity as a means to quality health care for all.
Simply offering MCAT modifications for Indigenous Peoples reflects DOS 2.0 organization—modifying a barrier to support success among medical students from an identified underrepresented group. DOS 3.0 organization, however, achieves diversity through inclusion to foster excellence and quality health care for all. Similarly, the first FMEC MD recommendation emphasizes social accountability and provision of high-quality health care to all Canadians (see List 1).7 To achieve this imperative and enhance medical student diversity through effective admissions practices, Canadian medical schools must adopt the DOS 3.0 principle of inclusion. This will require discontinuing the use of MCAT scores in admissions decisions instead of continuing the search for the correct MCAT (or MCAT2015) modification. Leadership of this type within medical education resonates with the final FMEC MD recommendation, Foster Medical Leadership (see List 1).7 Current MCAT modifications seem insufficient to meaningfully contribute to the changes necessary for fostering medical student diversity.
Those advocating for continued use of the MCAT (and adoption of the MCAT2015) exam will argue that there is insufficient evidence that the exam is responsible for the lack of progress toward diversity goals. The MCAT exam has iconic stature in medical school admissions, demonstrated by its role as a prestige marker for medical school rankings in U.S. News and World Report (USNWR).33 Yet these rankings, and the importance they place on MCAT scores, may undermine diversity efforts, as several researchers have demonstrated. McGaghie and Thompson,34 for example, identified that the USNWR medical-school-ranking methodology had a narrow perspective regarding contribution of admissions data to rankings and, instead, emphasized test scores such as those from the MCAT exam. They decry this narrowly focused, elitist ranking approach, for it ignores admissions policies that have improved medical student diversity by broadening the scope of admissions-relevant information and deemphasizing test scores.34 Sweitzer and Volkwein33 comment that the importance of standardized tests (for medicine, the MCAT exam) within USNWR graduate and professional school rankings may influence schools to prioritize such tests above other goals such as diversity.
How does this experience with medical school rankings in a U.S. publication relate to Canada’s MCAT exam use and medical student diversity? University-ranking publications are new to Canada, and their influence within Canada is still to be determined.15 However, Maclean’s (a Canadian national news magazine) rankings of the Canadian medical/doctoral universities are reportedly affecting secondary school graduates’ applications to these universities within the province of Ontario.48 An increased Maclean’s ranking for an Ontario medical/doctoral university was associated with an increase in applications to that university the following year. Thus, now is the time to acknowledge this potential for a shift to a hierarchical, prestige-oriented mentality because of the influence of rankings, and instead act to foster the FMEC MD’s social-accountability- and diversity-oriented goals (see List 1)7 and avoid relying on prestige rankings and prestige markers such as the MCAT exam.
Is the MCAT Exam a Strong Predictor of Future Performance?
A number of studies have assessed the predictive relationship between the MCAT exam and various outcomes in medical school and residency. A meta-analysis of 21 such studies found that the predictive validity of the MCAT exam ranges from small to medium for both medical school performance and medical board licensing exams.49 Donnon and colleagues49 showed that the MCAT exam, particularly the science sections, is most predictive of preclerkship grades and United States Medical Licensing Examination (USMLE) Step 1 scores. A study by Violato and Donnon20 used multiple regression analysis to show that three predictors (MCAT Verbal Reasoning score, MCAT Biological Sciences score, and GPA) accounted for 23% of the variance in the Medical Council of Canada Qualifying Examination Part 1, and that two predictors (MCAT Verbal Reasoning score and GPA) accounted for 11% of the variance in Part 2. MCAT scores are less associated with USMLE Step 2 Clinical Skills, Step 2 Clinical Knowledge (CK), Step 3, clerkship grades, and clinical performance in residency.50
Low MCAT scores also predict a greater likelihood of academic withdrawal or dismissal and failing the USMLE Step 1 and/or Step 2 CK on the first attempt.51 A study following two cohorts of students at 14 U.S. medical schools found that MCAT scores almost doubled the proportion of variance in medical school grades explained by undergraduate GPAs and were more predictive (and could even replace) undergraduate GPA in the prediction of USMLE Step 1, 2, and 3 scores.22 A more recent review of data from 119 U.S. medical schools demonstrates the robust ability of MCAT scores to predict academic success, generalized across schools.23 The MCAT exam thus performs extremely well in assisting schools in selecting students who are likely to complete training successfully.
Medical schools are also interested in predicting who will perform well after completion of medical school. Few data correlate admissions variables with practicing physician performance, and studies have instead focused on clinical performance in the last stages of medical school and residency as surrogate measures. Evidence suggests that the Verbal Reasoning section of the MCAT exam is the section most predictive of clinical performance (clerkship and residency); on the basis of this finding, McMaster University recently began using this section in their medical school admissions process.20,52,53 A Canadian study has also shown the value of the MCAT exam in predicting performance beyond preclinical years. A study of the rankings of University of Toronto applicants to a competitive internal medicine residency program, which is highly dependent on clinical performance in clerkship, demonstrated that MCAT scores correlated with applicant rank.21
The data outlined above demonstrate that the MCAT exam currently provides unique and invaluable evidence predicting applicant performance. The MCAT2015 exam is likely to increase the strength of this predictive ability, during and beyond basic science performance.
Because several Canadian medical schools do not have an MCAT exam requirement, the background knowledge necessary for the MCAT exam is not required for admissions decisions or prediction of performance for substantial numbers of medical students. Although it is appropriate to question whether the MCAT exam can predict future performance in the formal curriculum (i.e., measuring required background knowledge), we must also consider the influence of the hidden curriculum on future performance. The hidden curriculum is the socialization process of medical students shaped by the profession’s values and attitudes. The hidden curriculum exists not only outside of but at times contrary to students’ formal curriculum instruction regarding these same values and attitudes.54,55 We need to broaden the debate about student preparedness to include the hidden curriculum for two reasons. First, the fifth FMEC MD recommendation (see List 1) calls attention to the hidden curriculum as it comprises a “set of influences that function at the level of organizational structure and culture,” affecting the nature of learning, professional interactions, and clinical practice.7 Second, the hidden curriculum extends to the premedical environment, including its socialization processes and early professional development of medical students and physicians.56
The influence of the MCAT exam on premedical education has long been controversial. In 1978, Thomas57 criticized medical school admissions processes for their adverse effect on premedical education. Thomas denounced premedical students’ preoccupations with GPAs and science courses and recommended either dropping the MCAT requirement or making major changes to the test, emphasizing literature, languages, and history, and deemphasizing science. Thomas’ envisioned changes are dramatically different from the changes embodied in the MCAT2015 exam. In their updated perspective regarding the premedical curriculum, Gunderman and Kanter58 revisit the themes of Thomas’ commentary, noting its contemporary relevance. They note two of Thomas’ points that are particularly relevant to the premedical curriculum: (1) undergraduate education is as important to medicine’s future as is medical school, and (2) medical schools have an impact on undergraduate education. They describe this impact as transforming the university’s meritocracy into a “narrow-minded and mean-spirited ‘testocracy.’”58 This “testocracy” reflects students’ competitive, single-minded determination to maximize their scores within the equation “GPA + MCAT = MD” at the cost of their broader educational pursuits.58
Computer-based MCAT delivery and MCAT practice tests began in 2007.59 Now, the MCAT exam is offered more than 20 times per year, and computer-based practice tests increase the availability of representative practice materials. As a result of computer-based testing, applicants may take the MCAT exam more than once to increase scores, successful applicants increasingly attribute improved MCAT scores to MCAT computer-based practice tests, and computer-based practice tests have seen almost 50% sales growth (from 43,000 to 63,000 tests) between 2007 and 2009.59
These trends uncover a growing influence within the premedical hidden curriculum that prioritizes test-taking skills above reflective learning skills. This hidden consequence counters the MCAT2015 exam’s4 and the FMEC MD project’s7 aspirations regarding students’ learning skills. We must consider the premedical hidden curriculum in our use of the MCAT exam because its emphasis on test-taking skills and students’ competitive single-mindedness regarding grade and MCAT performance will undoubtedly affect future medical students’ longer-term performance. The FMEC MD report recommends examination of the hidden curriculum, and this recommendation should encompass the premedical curriculum. We must examine the future role of the MCAT exam within our admissions processes because its impacts within the premedical hidden curriculum are not congruent with the FMEC MD project’s educational aspirations for learners.
Should Canada Use the MCAT2015 Exam?
As we move through the 21st century, Canada’s medical schools are reflecting on how best to meet society’s health care needs. The populations we serve have changed, the incidence of complex chronic disease is rising exponentially, and the way physicians practice is evolving. The FMEC recommendations provide a considered set of guidelines to enable us to meet these challenges, placing a focus on the importance of social accountability, diversity, and humanistic values in selecting medical students, while emphasizing the importance of a core scientific knowledge base and the role of physicians in advocacy for public health and the prevention of disease. In this context, Canada’s medical schools are now assessing the potential effects of the MCAT2015 exam, which is concurrently emphasizing through content changes the importance of social determinants of health and the value of a broad humanistic preparation for a medical career.
From one perspective, we have outlined the benefits to be gained from a standardized assessment tool that reliably predicts performance in medical school and possibly beyond. Appropriately used, the exam appears to assist in selection of students to meet individual school mandates, including diversity goals. The MCAT2015 changes echo and harmonize with a number of FMEC recommendations: building on the scientific basis of medicine by updating the science sections, placing a new emphasis on the behavioral and social determinants of health, expanding the broad knowledge base expected of students, and further developing the test’s ability to assess the scientific and critical thinking and reasoning skills vital to clinical practice. The continued use of the MCAT exam and adoption of the MCAT2015 exam will provide essential applicant data and enhance the ability of Canadian schools to meet societal needs by selecting a student body capable of rising to the challenge.45
In counterpoint to these arguments, we have pointed out an alternative perspective: that using MCAT scores in admissions decisions and adopting the MCAT2015 exam will not advance multiple FMEC MD recommendations (i.e., Address Individual and Community Needs, Enhance Admissions Processes, and Address the Hidden Curriculum). In fact, adoption of the MCAT2015 exam presents risks to fulfilling FMEC MD goals regarding social accountability, medical student socioeconomic diversity, and the hidden curriculum and represents a lost leadership opportunity for Canada’s medical education community. Canada’s annual medical school admission decisions represent an opportunity to ensure that the physician mix meets our social accountability objectives. We believe that we have not yet met this goal, and with each new entering medical school class in which we do not redress these shortfalls, we repeatedly delay attainment of our national goals and the profession’s overarching social accountability goals as epitomized in the FMEC MD recommendations. Skochelak9 writes regarding medical education renewal that we have answered the question “What should we do?” and that now we must ask, “How can we get there?” In our opinion, for Canada, arriving at “We can get there” means advancing the FMEC MD report’s goals, which in turn requires discontinuing the use of the MCAT exam and not adopting the MCAT2015 exam.
In conclusion, we are reminded of Hamlet’s classic dilemma as we reflect on our own question: to use or not to use the MCAT2015 exam? We believe that Canada’s 17 medical schools possess the strength to provide medical leadership and understand the challenges embodied in considering this question. It is our intent that this Perspective article will help inform this national dialogue going forward.
Other disclosures: Dr. Eskander was previously an instructor in the Medical College Admission Test (MCAT) preparation course industry. Dr. Shandling was a member of the Association of American Medical Colleges MR5 Committee. Dr. Hanson reports that he has received meals paid for by MCAT staff in his capacity as associate dean, Undergraduate Medicine, Admissions and Student Finances.
Ethical approval: Not applicable.
* Indigenous is the term preferred by the Indigenous Physicians Association of Canada (IPAC) and most Indigenous groups; however, Aboriginal is the Canadian Census term for Indigenous groups (as Native American is the census term in the United States). The authors use both terms in this article. They have endeavored to use Indigenous except when referring to cited work that uses the term Aboriginal.
1. Dunleavy D, Sondheimer H, Castillo-Page L, Bletzinger RB. Medical school admissions: More than grades and test scores. AAMC Analysis in Brief. September 2011;11
2. MR5 Committee, Association of American Medical Colleges. . MR5: 5th Comprehensive Review of the Medical College Admission Test® (MCAT®). https://www.aamc.org/initiatives/mr5/
. Accessed January 30, 2013
4. Schwartzstein RM, Rosenfeld GC, Hilborn R, Oyewole SH, Mitchell K. Redesigning the MCAT Exam: Balancing multiple perspectives. Acad Med. 2013;88:560–567
5. Dienstag JL. The Medical College Admission Test—Toward a new balance. N Engl J Med. 2011;365:1955–1957
6. Kaplan RM, Satterfield JM, Kington RS. Building a better physician—The case for the new MCAT. N Engl J Med. 2012;366:1265–1268
8. Busing N, Slade S, Rosenfield J, Gold I, Maskill S. In the spirit of Flexner: Working toward a collective vision for the future of medical education in Canada. Acad Med. 2010;85:340–348
9. Skochelak SE. A decade of reports calling for change in medical education: What do they say? Acad Med. 2010;85(9 suppl):S26–S33
10. Young ME, Razack S, Hanson MD, et al. Calling for a broader conceptualization of diversity: Surface and deep diversity in four Canadian medical schools. Acad Med. 2012;87:1501–1510
11. Hanson MD, Lavallee B. Does Canada need a national diversity and admissions policy regarding the MCAT? Gravitas. 2010;43(4):11
12. Association of Faculties of Medicine of Canada. Admission Requirements of Canadian Faculties of Medicine: Admission in 2012. http://www.afmc.ca/pdf/2012_ad_bk.pdf
. Accessed January 30, 2013
15. Davies S, Hammack FM. The channeling of student competition in higher education: Comparing Canada and the U.S. J High Educ. 2005;76:89–106
16. Skolnik ML. Diversity in higher education: The Canadian case. Higher Educ Eur. 1986;11(2):19–32
17. Skolnik ML, Jones GA. A comparative analysis of arrangements for state coordination of higher education in Canada and the United States. J High Educ. 1992;63:121–142
20. Violato C, Donnon T. Does the Medical College Admission Test predict clinical reasoning skills? A longitudinal study employing the Medical Council of Canada clinical reasoning examination. Acad Med. 2005;80(10 suppl):S14–S16
21. Peskun C, Detsky A, Shandling M. Effectiveness of medical school admissions criteria in predicting residency ranking four years later. Med Educ. 2007;41:57–64
22. Julian ER. Validity of the Medical College Admission Test for predicting medical school performance. Acad Med. 2005;80:910–917
23. Dunleavy DM, Kroopnick MH, Dowd KW, Searcy CA, Zhao X. 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
24. Kondro W. Thinking of med school? Where do you live? CMAJ. 2007;176:157–158
25. Cohen JJ. Our compact with tomorrow’s doctors. Acad Med. 2002;77:475–480
26. McGaghie WC. Assessing readiness for medical education: Evolution of the medical college admission test. JAMA. 2002;288:1085–1090
27. Bardes CL, Best PC, Kremer SJ, Dienstag JL. Perspective: Medical school admissions and noncognitive testing: Some open questions. Acad Med. 2009;84:1360–1363
28. Collier R. New Medical College Admission Test in the works. CMAJ. 2011;183:E801–E802
29. Tompkins J. Money for nothing? The problem of the board-exam coaching industry. N Engl J Med. 2011;365:104–105
30. McGaghie WC, Downing SM, Kubilius R. What is the impact of commercial test preparation courses on medical examination performance? Teach Learn Med. 2004;16:202–211
31. White AN. The high cost of being an (aspiring) medical student. CMAJ. 2008;179:1228
32. Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of first-year students in Canadian medical schools. CMAJ. 2002;166:1029–1035
33. Sweitzer K, Volkwein JF. Prestige among graduate and professional schools: Comparing the U.S. News’ graduate school reputation ratings between disciplines. Res High Educ. 2009;50:812–836
34. McGaghie WC, Thompson JA. America’s best medical schools: A critique of the U.S. News & World Report rankings. Acad Med. 2001;76:985–992
35. Association of American Medical Colleges.. Applicants and matriculants data, Table 2: Undergraduate institutions supplying applicants to U.S. medical schools by applicant race and ethnicity, 2011. In: FACTS: Applicants, Matriculants, Enrollment, Graduates, MD/PhD, and Residency Applicants Data. 2011 Washington, DC Association of American Medical Colleges
36. Davis D, Dorsey JK, Franks RD, Sackett PR, Searcy CA, Zhao X. Do racial and ethnic group differences in performance on the MCAT Exam reflect test bias? Acad Med. 2013;88:593–602
38. Koenig JA, Sireci SG, Wiley A. Evaluating the predictive validity of MCAT scores across diverse applicant groups. Acad Med. 1998;73:1095–1106
39. Barton PE Parsing the Achievement Gap: Baselines for Tracking Progress. 2003 Princeton, NJ Educational Testing Service, Policy Information Center
40. Barton PE, Coley RJ Parsing the Achievement Gap II. 2009 Princeton, NJ Educational Testing Service, Policy Information Center
41. Barton PE, Coley RJ The Family: America’s Smallest School. 2007 Princeton, NJ Educational Testing Service, Policy Information Center
42. Tate WF Research on Schools, Neighborhoods, and Communities: Toward Civic Responsibility. 2012 Lanham, Md Rowman & Littlefield Publishers, Inc.
43. Association of American Medical Colleges. . Applicants and matriculants data, Table 25: MCAT and GPA grid for applicants and acceptees by selected race and ethnicity, 2009–2011 (aggregated). In: FACTS: Applicants, Matriculants, Enrollment, Graduates, MD/PhD, and Residency Applicants Data. 2012 Washington, DC Association of American Medical Colleges
44. Reiter HI, Lockyer J, Ziola B, Courneya CA, Eva KCanadian Multiple Mini-Interview Research Alliance (CaMMIRA). . Should efforts in favor of medical student diversity be focused during admissions or farther upstream? Acad Med. 2012;87:443–448
45. Kirch DG. Transforming admissions: The gateway to medicine. JAMA. 2012;308:2250–2251
47. Nivet MA. Commentary: Diversity 3.0: A necessary systems upgrade. Acad Med. 2011;86:1487–1489
48. Mueller RE, Rockerbie D. Determining demand for university education in Ontario by type of student. Econ Educ Rev. 2005;24:469–483
49. Donnon T, Paolucci EO, Violato C. The predictive validity of the MCAT for medical school performance and medical board licensing examinations: A meta-analysis of the published research. Acad Med. 2007;82:100–106
50. Callahan CA, Hojat M, Veloski J, Erdmann JB, Gonnella JS. The predictive validity of three versions of the MCAT in relation to performance in medical school, residency, and licensing examinations: A longitudinal study of 36 classes of Jefferson Medical College. Acad Med. 2010;85:980–987
51. Andriole DA, Jeffe DB. Prematriculation variables associated with suboptimal outcomes for the 1994–1999 cohort of US medical school matriculants. JAMA. 2010;304:1212–1219
52. Hojat M, Erdmann JB, Veloski JJ, et al. A validity study of the writing sample section of the Medical College Admission Test. Acad Med. 2000;75(10 suppl):S25–S27
53. Siu E, Reiter HI. Overview: What’s worked and what hasn’t as a guide towards predictive admissions tool development. Adv Health Sci Educ Theory Pract. 2009;14:759–775
54. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–871
55. Hafferty FW. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Acad Med. 1998;73:403–407
56. Gross JP, Mommaerts CD, Earl D, De Vries RG. Perspective: After a century of criticizing premedical education, are we missing the point? Acad Med. 2008;83:516–520
57. Thomas L. Notes of a biology-watcher. How to fix the premedical curriculum. N Engl J Med. 1978;298:1180–1181
58. Gunderman RB, Kanter SL. Perspective: “How to fix the premedical curriculum” revisited. Acad Med. 2008;83:1158–1161
59. Matthew D. AM last page: Evolving behaviors of MCAT examinees who apply to U.S. medical schools. Acad Med. 2010;85:1100