The Association of American Medical Colleges (AAMC) recently published two medical education reports updating required medical students’ competencies in the sciences1 and the behavioral and social sciences2: “Scientific Foundations for Future Physicians”1 from the AAMC and Howard Hughes Medical Institute, and the AAMC report “Behavioral and Social Science Foundations for Future Physicians.”2 In 2015, the AAMC will be implementing a new version of the Medical College Admission Test (MCAT), MCAT2015, with two new sections, which will test social sciences and humanities (SSH) knowledge: “Psychological, Social and Biological Foundations of Behavior” and “Critical Analysis and Reasoning Skills.”3,4 These reports and the MCAT2015 reflect current expert opinion regarding the contributions of natural sciences, behavioral and social sciences, and the humanities to medical student selection.
There is a long-standing debate regarding U.S. premedical education. That is, are students who majored in SSH disciplines as prepared as their science major counterparts, and do they perform as well in medical school? In his 1910 report, Flexner5 recommended sweeping changes to medical education including medical school admission policy. He described physics, biology, and chemistry, including laboratory experience, as foundational to the premedical curriculum, asserting that poor performance in these disciplines could identify unqualified applicants.6 Flexner’s ethos continues to permeate U.S. and Canadian medical schools, as most require some combination of prerequisite courses in science and mathematics. On the centenary of the Flexner report, scholars revisited the importance of humanities within premedical education.7,8 Riggs7 opined that the absence of humanities prerequisites should preclude medical school admission as does the absence of science prerequisites. In 1978, Thomas9 decried the detrimental impact of medical school admission policies on the premedical curriculum, criticizing premedical education’s emphasis on sciences at the expense of a liberal arts education. He suggested that premedical education should focus on the classics in literature, with in-depth study of sciences saved for medical school itself. He also suggested that the MCAT either be dropped entirely or changed to lessen the focus on sciences and increase the focus on literature, humanities, and history. In 2008, Gunderman and Kanter10 revisited Thomas’s commentary and considered it still to be relevant.
However, science prerequisites continue to be emphasized in medical school admission policies today. The AAMC Medical School Admission Requirements Guidebook identifies the 10 most common premedical course requirements,11 8 of which are science and mathematics courses (e.g., physics, organic and inorganic chemistry); only 2 are SSH courses (English and humanities). Muller and Kase12 report that, according to AAMC data, less than 18% of medical students matriculating in 2009 were SSH majors.
Given the long-standing debate about SSH premedical education, we pose the following question: Does SSH premedical education have a role in today’s medical school admission process? That is, should there be prerequisite SSH course requirements for all applicants? Should there be standards for how medical school admission committees consider and compare applicants with majors in SSH versus those with majors in the sciences? Although admission committees may have interest in applicants with SSH backgrounds, they may harbor skepticism regarding these applicants’ preparedness. To advance this debate, in this article we provide (1) a review of the literature regarding SSH in premedical education and (2) a contextualization of this review within today’s admission milieu. We believe this contextualization is necessary as aspects of the milieu are influential but hidden. Hafferty13 identifies the hidden curriculum embedded within medical schools’ messages to applicants that values science and devalues humanities. We also illuminate three premedical hidden curriculum factors: medical schools’ reliance on admission tools designed for and employed within the admission cycle itself as well as the commercialization of and globalization of admission processes. We conclude with an analysis of the literature review within the context of this hidden premedical curriculum.
Literature review: Scope and criteria for inclusion
We limited this literature review to the published literature on premedical education of medical school applicants. We compared premedical SSH education with premedical sciences education. For inclusion in the review, studies had to document the premedical education status of students (i.e., their majors), be written in English, and (1) incorporate an examination of how premedical education influenced performance during and/or after medical school or (2) describe interventions during medical school involving humanities components. Studies reporting either qualitative findings or quantitative outcomes were included. Studies describing medical school SSH educational interventions or curricular courses that did not provide information about students’ premedical education were excluded.
Literature review: Search terms and selection process
We searched the PubMed, MEDLINE, and PsycINFO databases for research published in English between 1910 and July 20, 2012. Search terms included humanities, premedical education, social sciences, science, arts, liberal arts, undergraduate medical education, clerkship, preclerkship, graduate medical education, residency, grades, attrition, graduation rate, dropouts, and achievement.
From May to July 2012, one of the authors (J.N.H.) conducted the initial search, eliminated duplicate articles, and reviewed the titles and abstracts of each remaining article to assess general fit within the scope of the current analysis. Non-English-language articles and studies where no data (either qualitative or quantitative) were available to extract were excluded. Bibliographies of relevant papers were examined for relevant references missed by the initial search. Remaining papers were reviewed in full against our inclusion and exclusion criteria. Two of the authors (J.N.H., M.D.H.) independently abstracted data from each article selected for final analysis, including study objectives and description, student comparison groups based on premedical background, definition of “humanities,” outcome measure(s), and results. We resolved conflicts by discussion with all three authors.
Part 1: Review of the literature
The initial search resulted in 1,548 records. We eliminated duplicates (858) and screened the remaining 690 article titles and abstracts to assess general fit within the scope of the current analysis. Non-English-language articles and studies where no data (qualitative or quantitative) were available to extract were excluded, resulting in 102 potentially relevant articles (see Figure 1). Remaining papers were reviewed in full against our inclusion and exclusion criteria. Twenty articles were included in the final analysis.12,14–32 All but 3 of the 20 were published before 2000. We categorized data abstracted from these 20 articles across five themes: an American experience, academic performance, clinical performance, residency selection, and SSH major or course(s) prerequisite requirements. This data categorization reflects distinct outcomes that we considered relevant to admission committees. Table 1 presents the full characteristics and outcomes of each specific article included in our review.
An American experience.
The touchstone for this debate of whether SSH premedical education should influence medical school admission decisions rests within the U.S. premedical education system, with 14 studies from U.S. medical schools. This American concentration of SSH premedical education research likely reflects the U.S. tradition of liberal arts college education.10
The Humanities and Medicine Program (HuMed) at Mount Sinai School of Medicine (MSSM) offers the most compelling evidence for the advancement of SSH premedical education.12,14 HuMed is designed as an SSH-specific admission stream, offering guaranteed medical school admission (contingent on successful completion of an undergraduate degree) to some second- and third-year students majoring in the humanities or social sciences. Students are required to maintain a minimum grade point average (GPA) of 3.5 in addition to earning a “B” grade in biology and general chemistry. They are not required to take organic chemistry, physics, calculus, or the MCAT exam.12,14 Other components of HuMed admission include high school and university transcripts, two personal essays, three letters of reference, SAT scores, and two interviews.12 Once accepted, HuMed students must spend eight weeks after their third undergraduate year gaining clinical experience, attending seminars on medical topics such as bioethics and health policy, and taking an accelerated course on the “Principles of Organic Chemistry and Physics Related to Medicine.”12 HuMed students are invited to a summer enrichment program before commencing medical school to familiarize themselves with clinical sciences teaching.12
In a study conducted before HuMed implementation, Yens and Stimmel15 found that nonscience majors performed on par or better than their peers with science premedical education on the majority of performance measures and were significantly more likely to perform at the superior level of the National Board of Medical Examiners (NBME) Part II Psychiatry subtest.
In the two HuMed studies included in our review,12,14 no significant academic disadvantage was reported for HuMed students in terms of higher rates of serious academic difficulty in the first or second year of medical school12 or attrition rates.14 HuMed students did, however, take significantly more nonscholarly leaves for personal, academic, or psychiatric reasons,12 with a subset of HuMed students not performing well academically because they lacked the commitment necessary for medical education.14 Preclerkship performance ratings (United States Medical Licensing Examination [USMLE] Step 1 plus first- and second-year basic science courses)14 were weak. Yet clerkship performance ratings (Comprehensive Clinical Assessment [COMPASS] II, clerkship performance)12 indicated basic equivalency, and those HuMed students with multiple clerkship honors often were those who had experienced USMLE Step 1 or basic science performance difficulties.14 HuMed students demonstrated enhanced performance outcomes and a predilection for psychiatry and primary care specialties. HuMed students excelled in psychiatry12,14 and pediatric14 clerkships, and they were more likely than other medical students to select primary care and psychiatry residencies.12 HuMed and other medical students attained similar graduation research distinctions, but HuMed students were significantly more likely than other students to be recipients of Doris Duke Clinical Research Fellowships and to undertake a research year.12
Seventeen studies focused on assessing the relationship between premedical education and medical school performance.12,14–29 Generally, these studies reported basic equivalency in academic performance irrespective of premedical education. Outcomes compared included GPAs for each year of medical school, NBME and USMLE scores, delayed graduation and attrition rates, rates of academic difficulty, and average class ranking (see Table 1). Yet, variations in patterns of competencies were identified as illustrated in these studies.
Caplan and colleagues22 found that the grades of first-year medical students who had not taken advanced science courses were equal to those of students with stronger premedical science backgrounds. The exception was biochemistry, where those with prior biochemistry experience had significantly higher grades. Koenig18 reported that although there was no significant difference between broadly prepared and science-focused medical students’ NBME Part I scores, science-focused students achieved higher mean scores for three science subtests, and broadly prepared students achieved higher mean scores for the behavioral sciences subtest.
Although multiple studies reported similar attrition rates,14,16,27 other studies have reported contrasting findings. Neame and colleagues23 found that a weak background in the humanities and English was associated with higher-than-expected premature withdrawal and exclusion from the medical program prior to completion on academic grounds. However, Ashikawa and colleagues17 reported that students with humanities and arts premedical education experienced a higher attrition rate, commonly due to a change in their interest in medicine. Similarly, other research has shown that students with humanities degrees were the most common student subgroup to consider quitting medical school.16
Thirteen studies focused on assessing the relationship between premedical education and clinical performance in medical school and beyond.12,14,16,19,20,24–28,30–32 Multiple studies reported basic equivalency of clinical competence across medical students, residents, or physicians irrespective of premedical education.16,19,20,27,28,31,32 Outcomes compared included performance in clinical clerkships, first-year residency clinical performance ratings, humanism scores, patient-centered attitudes, and various clinical competencies (see Table 1). The studies also reported different clinical competency patterns based on SSH premedical education.
HuMed students’ clerkship competencies were basically equivalent with those of non-HuMed students except for HuMed students’ excellent performance in psychiatry and pediatric clerkships.12,14 Rolfe et al25 found that interns with premedical study in humanities and sciences achieved higher performance ratings as compared with interns with premedical study in sciences. Linn et al30 surveyed postgraduate physicians (interns, second-year postgraduates, third-year postgraduates, and faculty) and found that physicians with more SSH premedical courses had significantly higher self-reported humanism scores and humanism ratings by nurses.30
Koenig18 and Dickman et al19 found no significant differences in specialty choice between medical students with SSH and science premedical education. However, two studies12,16 identified an association between graduates with SSH premedical education and an increased likelihood of selecting primary care or psychiatry careers. Muller and Kase12 reported that HuMed students were more likely to select residencies in primary care or psychiatry. Zeleznik et al16 found that graduates with an undergraduate science degree were more likely to select an internal medicine or surgery residency, whereas those with an SSH degree were more likely to select a psychiatry residency.
SSH major or course(s) prerequisite requirements.
Many of the U.S. and Canadian studies that we reviewed characterized SSH premedical education on the basis of the number of credits students earned in SSH. Beneficial outcomes were commonly associated with an SSH major or significant course concentration.12,14–21,27–29 However, U.S. and Canadian medical schools commonly have admission prerequisites of only individual SSH course(s)—half of U.S. and Canadian medical schools have admission requirements or recommendations of one social or behavioral science course4—rather than an SSH major or a significant SSH course concentration.
Part 2: Contextualization within today’s admission milieu
Our central question for this literature review is, Does SSH premedical education have a role in today’s medical school admission process? That is, should there be prerequisite SSH course requirements for all applicants? Should there be standards for how medical school admission committees consider and compare applicants with majors in SSH versus those with majors in the sciences? Our review of the literature attests to such a role for SSH premedical education. Applicants with SSH premedical education are adequately prepared for medical school. Furthermore, medical students and medical school graduates with more SSH premedical education demonstrate enhanced performance in pediatrics and psychiatry clerkships and clinical skills reflective of humanism and could contribute to solving health human resourcing problems associated with primary care and psychiatry physician workforce shortages.33,34
Yet, contemporary research advancing SSH premedical education within admission decision making is limited, with only a few publications since 2000 included in our literature review. In contrast, the new MCAT2015 and the associated examination development process of updating and reviewing premedical education are garnering (and will likely continue to do so) significant scholarly and research interest.3,4 In an effort to better understand this contrast, we return to the premedical hidden curriculum as discussed by Thomas,9 Gunderman and Kanter,10 and Hafferty13 by advancing the discussion regarding the premedical hidden curriculum to include three themes regarding today’s admission milieu: reliance on admission tools, and commercialization of and globalization of admission processes.
One of the author’s (M.D.H.) long-standing administrative and scholarly inquiry regarding medical school admission processes enabled this contextualization of the SSH premedical curriculum within the broader premedical hidden curriculum.
Reliance on admission tools.
U.S. and Canadian medical schools identify great importance to and rely heavily on tools developed for and employed during the admission cycle. The MCAT exam is used by the majority of medical schools in the United States and Canada.35 All medical schools in the United States36 and Canada use admission interviews; close to one-quarter of medical schools in these countries employ the Multiple Mini Interview (MMI).37
The AAMC surveyed medical school admission officers across the United States and Canada about the decision-making importance of various admission materials.38 Of 11 items, MCAT total score was the third most important item for interview selection; the other top items were (1) GPA (cumulative sciences and math) and (2) GPA (cumulative).38 Of 12 items, admission interview recommendations were the most important for selecting applicants for admission.38 Completion of premedical requirements was of particularly low importance for both interview selection and admission.38
The competencies blueprinting process for the MCAT2015 exam recognized the importance of humanities, social, and behavioral sciences.4 However, this extensive process required blueprinting compromise as the range of topics in social and behavioral sciences suggested for testing would have required complicated testing formats and lengthened examination duration greatly.4 The compromise reached was to test social and behavioral sciences competencies studied in introductory psychology and sociology courses within the new “Psychological, Social and Biological Foundations of Behavior” section. In terms of the humanities and social sciences, discipline testing of ethics, cultural studies, philosophy, and population health were also thought important.4 However, concerns were raised that adding these additional topics to the already-extensive range of topics for MCAT2015 might disadvantage specific applicant subgroups. For instance, applicants from lower socioeconomic groups might be disadvantaged because of the additional tuition costs associated with such course work. The compromise reached was to use SSH text passages, not discipline-specific knowledge, to test critical analysis and reasoning skills within the new “Critical Analysis and Reasoning Skills” section.4
With this compromise, the MCAT2015 test designers’ goal was to encourage applicants to read broadly within the area of SSH in preparation for medical school. The MMI does not require SSH background study. Reliance on these admission tools will not require or encourage applicants to enroll in SSH majors or significant course concentrations, which our review associates with beneficial outcomes.
Commercialization of and globalization of admission processes.
U.S. and Canadian medical schools’ reliance on admission tools for admission decision making has been accompanied by a commercial transformation of the admission process. This medical school admission marketplace comprises tools including the MCAT exam,39 the MMI,37,40 and test preparation courses.41–43 Tompkins43 notes that although proprietary medical schools may have disappeared post Flexner, business interests now focus on test preparation courses. MCAT preparation courses are one facet of this multi-million-dollar business. In 2011, 91,600 MCAT exams were completed.44 Between 2007 and 2009, MCAT computer-based practice test sales increased by almost 50%.41,45 Moreover, from 2010 to 2012, 61.3% to 65.3% of matriculating medical students reported using MCAT preparation courses, and more than one-third of medical school matriculants annually report taking the MCAT exam multiple times.46 The company ProFitHR has monetized the MMI, offering customizable MMI materials that can be applied across a range of tasks with applicants to medical, pharmacy, veterinary, and dental schools.37,40
Furthermore, medical education is in a phase of global expansion.47–49 U.S. medical schools are expanding48 with global collaborative ventures such as the Weill Cornell Medical College in Doha, Qatar; the DUKE-NUS Medical School and Research Center in Singapore; and the Medical School for International Health (Ben Gurion University), a joint venture with Columbia University Medical Center in Beer-Sheva, Israel—all of which employ the MCAT exam.50–52 There are MCAT test-taking centers in 21 countries outside of the United States.53 ProFitHR reports MMI use across Europe, the Middle East, and the Far East.40 SSH premedical education presence within this global expansion is reflected not in SSH majors but instead in a premedical SSH course in medical ethics and humanities for premedical students as reported at the Weill Cornell Medical College in Qatar.52 We contend that these evolving impacts of medical schools’ reliance on admission tools, commercialization, and globalization foreshadow increasing global implementation of the MCAT and MMI and increasing marginalization of SSH premedical education.
Discussion and Conclusions
Our literature review findings suggest that meaningful consideration of SSH premedical education is warranted within the medical school admission process. A formal means by which medical school admission committees consider applicants with premedical majors in SSH independently of, or in comparison with, applicants with premedical majors in the sciences should be devised and implemented. The studies reviewed indicate that the academic, clinical, and research performance of medical students with SSH premedical education is equivalent to that of other medical students, but different patterns of competencies exist. For example, although research distinction is similar, increased clinical research interest is associated with SSH background.12 Enhanced performance outcomes in and career preferences for psychiatry and primary care specialties such as pediatrics are reported for students with SSH backgrounds.12,14 Notably, these career preferences may present a health human resourcing opportunity to address long-standing primary care and psychiatry physician shortages.33,34 A valuable post-medical-school outcome associated with SSH premedical background is equivalent or improved clinical performance,25 which should mollify admission committees’ skepticism regarding SSH applicants’ preparedness.
These findings, however, are insufficient to advance the discourse regarding SSH premedical education in a consequential manner. SSH premedical education has been relegated to a minor place within the current admission milieu. The increasing adoption of the MCAT and MMI across the globe surpasses adoption of SSH premedical education requirements. We assert that the hidden premedical curriculum embodied in the reliance on admission tools, commercialization, and globalization has contributed to and will continue to accentuate the marginalization of SSH premedical education.
Although the MCAT2015 exam blueprinting process recognized the importance of the humanities and of social and behavioral sciences,4 we believe it does not go far enough, and applicants will behave strategically in their SSH course selections and readings to remain competitive for the MCAT2015 exam, likely narrowly selecting introductory psychology and sociology courses, rather than selecting and reading broadly within SSH as predicted.4 The current MCAT exam predicts clinical performance outcomes,41 as does the MMI.37 The MCAT exam and MMI enable selection of medical students with the potential for strong clinical skills, irrespective of SSH premedical education status. Because clinical skills are an important admission outcome, continued reliance on these tools may render SSH premedical education irrelevant.
With this reliance on admission tools and associated research, we overlook the HuMed program’s long-term, programmatic approach to evaluation.12,14 It is on par with the long-term, programmatic approach to evaluation taken by MMI researchers.37 While the MMI is being implemented across the United States, Canada, and globally, SSH premedical education’s acceptance as legitimate premedical preparation continues to be debated.
Going forward, it is unlikely that SSH premedical education will supplant the emphasis on science premedical education in the medical school admission process. However, three approaches could be explored to better incorporate the beneficial outcomes of SSH premedical education. First, medical schools with a mission to graduate primary care physicians could actively recruit prospective applicants with SSH majors or concentrations.
A second approach would be adoption of an SSH admission stream as one component of a school’s overall admission process, similar to MSSM’s successful approach with its HuMed Program. This HuMed approach may foster, as it has at MSSM,54,55 a cultural shift as faculty consistently experience the selection of medical students with graduation success on par with (or sometimes better than) their peers with premedical science education. Indeed, MSSM is transforming the HuMed program with its expanded FlexMed program.55 Although a school’s culture may have to shift to accommodate medical students with an SSH background who need early, additional support for science-based preclerkship courses, ultimately these students will excel and graduate alongside their peers. The move to competency-based education, as encouraged by recent medical education reports,1,2 may catalyze this cultural change and an adoption of SSH admission streams.
SSH-specific admission streams like HuMed have additional benefits: decreased premedical educational costs and increased student interest in clinical research.12 The HuMed model12,14 does not require its applicants to take the MCAT, which eliminates the premedical education cost barrier of the MCAT exam and its associated preparation courses.41 HuMed students experience similar research distinction as their peers but significantly more often receive Doris Duke Clinical Research Fellowships.12 This fellowship program is specifically designed for medical students interested in clinical research, not basic science research, and serves as a complement for MD-PhD programs, which commonly attract students with basic science research interest.56
In a third approach, medical schools could revise their admission policies to include more than a single or limited number of SSH course prerequisites, as single or limited SSH course prerequisites policies may not have the intended educational outcomes. SSH premedical education with either an SSH major or course concentration, not simply SSH course counts, was associated with the beneficial outcomes noted in our review.
Adoption of any of these three appro aches should be accompanied by renewed SSH premedical educational research; such research is necessary to legitimize SSH premedical education within medical school admission pro cesses. A particular focus for research is an improved understanding of changed or loss of commitment to medical education experienced by a subset of medical students with SSH premedical education.12,14,16,17
Our literature review has limitations. First, we restricted our search to articles published in English. Second, the reviewed studies were heterogeneous, reporting on a wide variety of outcomes including traditional markers of academic and clinical success (e.g., GPAs, NBME and USMLE scores, pass rates) as well as other measures (e.g., COMPASS II scores, patient satisfaction, leadership and community service points). Because few studies used the same metrics, and we included both qualitative and quantitative studies, we were unable to conduct a meta-analysis or to assess publication bias. Finally, studies’ definition of SSH background was variable in terms of number of courses or specific disciplines encompassed within these domains, making it difficult to offer a clear recommendation regarding ideal SSH premedical background(s).
It is unlikely that SSH premedical education will attain a significant admission role across U.S. and Canadian medical school admission processes. However, a meaningful role is possible at medical schools that adopt competency-based educational models beginning at admission and medical schools with a primary care mission.
Acknowledgments: The authors would like to thank Justine Garrett for her help with preparation of the manuscript.
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