Pre-Med’s New Priorities: Heart and Soul and Social Science
Published: April 13, 2012
PROF. PIERS J. HALE knew something was up when his students at the University of Oklahoma were clamoring this spring to get into his medical ethics class, which was formerly populated largely by social science majors. What led to the sudden burst of popularity, he discovered, were plans by the Association of American Medical Colleges to revise the medical school admissions test to incorporate a hefty dose of social science.
A Second Opinion: The Post-Baccalaureate (April 15, 2012)
In addition to the hard-science and math questions that have for decades defined this rite of passage into the medical profession, nearly half of the new MCAT will focus on squishier topics in two new sections: one covering social and behavioral sciences and another on critical analysis and reading that will require students to analyze passages covering areas like ethics and cross-cultural studies.
“Enrollment doubled and I had to turn 20 away,” said Professor Hale, a professor of the history of modern science. “But what’s really exciting is not that taking this class will get these kids into medical school, but that it will help them become better physicians.”
The Medical College Admission Test is, of course, much more than a test. A good score is crucial for entry into a profession that is perennially oversubscribed. Last year, nearly 44,000 people applied for about 19,000 places at medical schools in the United States. So the overhaul of the test, which was announced last year and approved in February, could fundamentally change the kind of student who will succeed in that process. It alters the raw material that medical schools receive to mold into the nation’s future doctors.
Which is exactly what the A.A.M.C. has in mind. In surveys, “the public had great confidence in doctors’ knowledge but much less in their bedside manner,” said Darrell G. Kirch, president of the association, in announcing the change. “The goal is to improve the medical admissions process to find the people who you and I would want as our doctors. Being a good doctor isn’t just about understanding science, it’s about understanding people.”
The adoption of the new test, which will be first administered in 2015, is part of a decade-long effort by medical educators to restore a bit of good old-fashioned healing and bedside patient skills into a profession that has come to be dominated by technology and laboratory testing. More medical schools are requiring students to take classes on interviewing and communication techniques. To help create a more holistic admissions process, one that goes beyond scientific knowledge, admissions committees are presenting candidates with ethical dilemmas to see if their people skills match their A+ in organic chemistry.
The big question, of course, is how well a multiple-choice test can help screen for the ethereal mix of scientist and humanist and spiritualist that makes a good doctor. That is uncharted territory.
“Yes, we’ve fallen in love with technology, and patients are crying out, saying, ‘Sit down and listen to me,’ ” said Dr. Charles Hatem, a professor at Harvard Medical School and an expert in medical education. “So what the MCAT is doing has a laudable goal. But will recalibrating this instrument work? Do more courses in the humanities make you more humane? I think the best we can say is a qualified maybe.”
And then there are the more immediate concerns of pre-med students and their colleges, which are preparing for the seismic changes.
Where will students find time to take in the extra material? How to prepare pre-med students long primed to answer questions like “Where are the serotonin receptors 5-HT2A and 5-HT2B mostly likely to be located in hepatocytes” to tackle more ambiguous challenges, like: “Which of the following explanations describes why the Identity vs. Role Confusion stage likely affects views about voting and being a voter?”
The first class to experience the new test, which is traditionally taken junior year, will enter college this fall. Some current students could face it, too, as it has become increasingly popular to take a gap year or two before applying to medical school.
“I can definitely see students panicking about this,” said Dr. W. Alexander Escobar, director of the pre-medical mentoring office at Emory University, who is preparing new recommendations for coursework.
I should disclose that I have a history here: when I took the MCAT in the late 1970s, the test was all about basic science, which was not at all my interest; I had worked in labs and hated it. To make matters worse, the test was the day after my 21st birthday. That landmark celebration was lost to miserable cramming in physics formulas and biological pathways.
But I went to medical school in the 1980s — heady years for basic science, when new technologies like M.R.I.’s expanded diagnosis, fiber-optic instruments allowed for minimally invasive surgery and recombinant gene experiments paved the way for new tests and medicines that could cure hard-to-treat diseases. Medical schools saw their primary mission as churning out researchers, biomedical engineers and academics who could apply the latest research on gene splicing to the treatment of cancer.
“With the growth in scientific knowledge, we were focused on making sure doctors had a good foundation in hard science,” Dr. Kirch said. Indeed, from 1942 to 1976, the MCAT had included a broad-based knowledge section called “Understanding Modern Society.” Liberal arts questions were eliminated in 1977.
Over the next two decades, the pressure in medicine to maximize the technology and minimize the healing arts only increased, as efficiency-oriented health care systems gave doctors less time to talk to patients, and insurance reimbursements rewarded doctors with high-tech specialties like radiology or those who performed procedures.
“I’m not a Luddite,” Dr. Hatem said, noting that the tide appears to be turning. “I know the importance of technology and testing advances, but we’ve let this substitute for listening and examining.”
Some experts have long identified the MCAT as a stumbling block in the often-failed quest to produce more caring, attentive doctors. It is a test that selects more for calculation skills than empathy. “The definition of readiness for medical education clearly has an academic component that the MCAT has captured well,” Dr. William McGaghie, a professor at Northwestern University, wrote a decade ago in the Journal of the American Medical Association. “But it also has professional and personal components, as yet unmeasured or measured poorly.”
And so the Association of American Medical Colleges began three years ago to redesign the MCAT, surveying thousands of medical school faculty members and students to come up with a test tailored to the needs and desires of the 21st century. In addition to more emphasis on humanistic skills, the new test had to take into account important new values in medicine like diversity, with greater focus on health care for the underserved, Dr. McGaghie said.
As a result, there will be questions about gender and cultural influences on expression, poverty and social mobility, as well as how people process emotion and stress. Such subjects are “the building blocks medical students need in order to learn about the ways in which cognitive and perceptual processes influence their understanding of health and illness,” explains the preview guide to the new MCAT.
While the guide avers that such material is generally covered in introductory psychology and sociology classes, surveys by Kaplan Test Prep have found that fewer than half of pre-med students currently take these courses, said Amjed Saffarini, executive director of Kaplan’s pre-health programs. The company estimates that the changes, including more advanced science questions on genetics and biochemistry, could effectively double the coursework for med school admission.
Getting pre-med preparation right is a high-stakes game for colleges, which attract applicants because of their medical school admissions rates. Virtually all are now scrambling to figure out how to revise pre-med programs. Will all students on the pre-med track be required to take psychology and sociology, for example?
Many colleges and universities say they are not ready to discuss plans. Columbia University, said Katherine Cutler, its director of communications and special projects, “has been evaluating its curriculum and, based on this review, will make recommendations for ways to prepare Columbia’s students for the new content.”
At Emory, Dr. Escobar has asked social science departments to advise him on which of their courses cover the topics outlined in the new MCAT preview guide, so as to advise pre-med students about what to take. “We don’t want to design a course specifically for pre-meds,” he said. “We want them to take what’s already there.”
Many colleges already require pre-med students to take distribution requirements in the social sciences, said Joy Kiefer, an assistant dean at Washington University in St. Louis. “Physicians need a solid foundation in not just science but behavioral science to get good patient outcomes,” she added.
But for pre-meds, such courses have long taken a distant back seat to core science courses. While pre-med students can choose any major, only 5 percent come from the humanities and 12 percent from social sciences. More than half of all applicants majored in biological science.
The mere fact that psychology, sociology and critical thinking will be on the MCAT is likely to change priorities, prompting science majors to think harder about topics like the perception of pain, informed consent, community awareness and the ethics of the Tuskegee Syphilis Experiment. “We wanted to send a strong signal at the undergraduate level that these are important elements,” Dr. Kirch said.
For students already juggling heavy courseloads of organic chemistry, physics and laboratory research, that prospect is somewhat daunting. “From what I’ve understood, the test will be more difficult,” said Farrah Bui, 20, a sophomore pre-med student at Princeton who is considering taking time off before medical school and thus might have to take the new test. “It’s difficult enough with so many stresses already,” she said. “I’d say, it’s discouraging — another thing I have to do.”
Still, Ms. Bui is finding value in the medical anthropology course she is taking this semester, and believes such courses are useful for producing better doctors. “I used to think of medicine as very methodical: you get the symptoms, find the diagnoses and treat,” she said. “Now it has made me think beyond pathology and biochemistry to the person. It’s made me think, ‘How will I communicate with them?’ ”
Professor Hale at Oklahoma said that, with a far larger component of pre-meds in his class, he had fielded new types of questions. “When pre-meds approach an ethics class, at first it’s: just tell me what to do to be ethical,” he said. “They’ll come saying they’ve been put in the class by an adviser, but then discover it’s relevant.”
How admissions officers will use the new information remains to be seen. Though medical schools say they want a test that selects for more well-rounded students, their reputations derive far more from the number of Nobel Prize winners they spawn, not from producing good bedside doctors.
And, anyway, can a standardized test — even one six and a half hours long (current duration: four and a half hours) — really discern the students most capable of giving emotionally to their patients, or measure facility with profound concepts like discrimination and morality and the emotional underpinning of disease? After all, few ethics professors rely on multiple-choice tests. The writing section on the current MCAT is being dropped because admissions officers said it was unhelpful, and largely ignored it.
The 153-page MCAT preview guide lays out what students need to know in detailed outlines that read like formulas for a math test. To wit, a part of a section on emotion:
Three components of emotion (cognitive, physiological, behavioral).
Universal emotions (fear, anger, happiness, surprise, joy, disgust and sadness).
Adaptive role of emotion.
Theories of emotion (James-Lange theory, Cannon-Bard theory, Schachter-Singer theory).
The Association of American Medical Colleges will be field-testing new questions over the next two years by tacking an ungraded section onto the current MCAT. But Dr. Escobar of Emory said that sociology professors were concerned that some of the required topics in the outline seem dated. Liberal arts colleges do not want their intro to sociology class defined by what’s on the MCAT.
The A.A.M.C. says the goal of the new MCAT is not just to find out what students know, but also how they think and who they are. And that kind of test is harder to cram for. “We’re not in the business of changing personalities,” said Dr. Saffarini of Kaplan Test Prep. “But we can offer practice scenarios.”
Dr. Hatem had this to say: “I know what society needs and what patients want. They want a doctor who is technically competent but who also understands who they are. How to get there is more complicated.”