Premedical Education

Perspective: After a Century of Criticizing Premedical Education, Are We Missing the Point? Jeffrey P. Gross, Corina D. Mommaerts, David Earl, and Raymond G. De Vries, PhD

Abstract Ever since Abraham Flexner formalized century-long conversation about attitudes about premedical education; the idea of premedical education in premedical education, highlighting the for example, premedical advisors regard 1910, medical educators have argued themes of that discussion and the the “sifting process” of premedical about how best to prepare students for important aspects of being a “premed” education as a “journey of discovery,” medical school. This back-and-forth that have not been a part of the whereas students describe their about the premedical years has focused conversation. From their systematic premedical years as a competition. The almost exclusively on the range and review of college and university Web authors’ work suggests a new approach content of the required course work; sites designed for premedical students to premedical education, an approach noticeably absent from the debate is and from comments collected from a that combines the coursework needed to consideration of the ways in which the symposium on the premedical years, the succeed in medical school with formal experience of the premedical years— authors describe how life as a premedical opportunities to reflect on both the including the curricular and noncurricular student, and not just curricular content, positive and pernicious effects of the demands placed on students—shape the teaches important lessons about what it premedical years. moral education of the next generation means to be a professional. The authors of physicians. The authors review the also report important disparities in Acad Med. 2008; 83:516–520.

The making of a physician begins long premedical education (most of which is what students know, but also how they before the first day in medical school. A based on opinion rather than research), but know, and thus, who they are. young person’s interest in becoming a its focus is on the courses premedical doctor often develops in the junior high students should or should not take, on the We know that classroom instruction is and high school years and shapes a things a premed must know to succeed in not sufficient to produce morally proper would-be physician’s choice of secondary medical school and as a physician. conduct: witness the recent report that a school courses, university or college, and required course in ethics at Duke undergraduate major. Given the Curiously, and despite the oft- University’s Fuqua School of Business did important role of premedical education acknowledged importance of not prevent cheating.3 When it comes to in shaping the physician work force, it is extracurricular activities for the premedical education, however, the debate surprising that so little research has been development of future physicians, would- goes on as if content trumped context, as if done on how the experience of being be reformers of premedical education the socializing experience of being a a premedical student shapes the focus almost exclusively on curricular “premed” did nothing to influence the knowledge, character, and moral lives of reform, as if the syllabus were all that behavior of future medical professionals. would-be physicians. There has been a mattered in the making of a physician. We must realize that when it comes to steady, albeit scant, stream of criticism of moral education, how students learn Generally, these calls for reform lack an (including the environment in which they appreciation of what might be termed the are learning) may be more important than “hidden premedical curriculum”: the Mr. Gross is a graduate of the Department of what they learn. Psychology, University of Michigan, Ann Arbor, many things learned directly and Michigan. indirectly from professors, advisors, peers, It is no secret that, for medical school Ms. Mommaerts is a graduate of the Department parents, “how-to” books, the media, and candidates, the undergraduate years serve of Economics, University of Michigan, Ann Arbor, the extracurricular experiences that have Michigan. to separate the wheat from the chaff. Far become de rigueur for admission to medical more students identify themselves as Mr. Earl is a graduate of the Department of school. The role of the hidden curriculum Sociology, University of Michigan, Ann Arbor, premeds in the first and second years of Michigan. in medical education has long been college than complete the premedical acknowledged.1–2 Not surprisingly, this requirements, and not all successful Dr. De Vries is associate professor, Department of 4 Medical Education and Bioethics Program, University larger curriculum is also critical to the premeds gain entry to medical school. of Michigan Medical School, Ann Arbor, Michigan. socializing experience of premedical What strategies must students develop in Correspondence should be addressed to Dr. De students, introducing them to, and order to succeed as premeds? What are Vries, Bioethics Program, University of Michigan, instructing them in, the competitive the moral implications of this hidden School of Medicine, 300 North Ingalls Street, Rm. strategies they will need in order to succeed premedical education? The discussion of 7C27, Ann Arbor, MI 48109-5429; telephone: (734) 936-5222; fax: (734) 936-8944; e-mail: in their medical training. The hidden premedical education has ignored these ([email protected]). premedical curriculum shapes not only important questions. Those calling for

516 Academic Medicine, Vol. 83, No. 5 / May 2008 Premedical Education reform of premedical education pay of a baccalaureate education led him to found in the comments of a third set of insufficient attention to the lives of lament the “baleful and malign” critics who are concerned that premedical premedical students and to the ways the influence of the modern medical school preparation lags behind the science and premedical years shape these students’ on the liberal arts: practice of medicine. Page10 recommends values and behavior. To begin a richer constant vigilance: conversation about the process of I have a suggestion, requiring for its implementation the following becoming a doctor, we review a century Although most schools now require announcement from the deans of all ‘minimum’ amounts of biology, of criticism of premedical education, the medical schools: henceforth, any chemistry, and physics, there does not offer a glimpse of the path to medical applicant who is self-labeled as a seem to be a clear rationale for these school from the point of view of a “premed,” distinguishable by his course prerequisites....Arethecourses needed premed, and reflect on how the selection from his classmates, will have to give the student a foundation of premedical years influence the moral his dossier placed in a third stack of three. knowledge important for his medical education of a physician. Membership in a “premedical society” studies? Must he have these intellectual will, by itself, be grounds for rejection. tools to practice medicine? Any college possessing something called a “premedical curriculum,” or maintaining 11 Premedical Education: A History Writing in 2006, Emanuel’s critique is offices for people called “premedical the most recent example of the “keep it of Critique advisors,” will be excluded from current” concern. He notes: What should one do to prepare for recognition by the medical schools. medical education? Before Abraham Many premed requirements are irrelevant Less radical than Thomas, but Flexner’s5 1910 report, Medical Education to future medical education and practice. nonetheless concerned with the in the United States and Canada, Does knowing how to integrate sin␪ have overemphasis on the hard sciences in requirements for entry to medical school anything to do with caring for a patient or premedical education, are those critics elucidating the role of TERC in aplastic were highly varied. Some schools who push for more humanities and social anemia? Do any physicians, even required completion of a collection of sciences in the premedical curriculum. As researchers, have to know about Diels– preparatory courses, whereas others early as 1937, Reinke7 worried that Alder adducts? Is calculating the angular required only money enough to pay the momentum of a spinning top relevant to doctors were becoming technicians: tuition. Today, as a result of the Flexner any medical practice? Most of what is “Does the modern physician have any report and the work of the Council on contained in one year of calculus, organic better insight into human nature than his chemistry, and physics is irrelevant to Medical Education of the American predecessor? Is he a doctor in the ancient medical practitioners, researchers, and Medical Association, a rigorous, science- meaning of the word, or is he only a administrators. oriented premedical education is the sine healer of organs?” His remedy? “To catch qua non for entry to medical school. In the vision of past generations, the Emanuel acknowledges that many of the the pre-Flexner years, any student with wisdom of the poet and the seer, we must requirements of premedical education are enough money could become a turn to literature.” More than 40 years outdated and serve simply to “weed out” physician; today, gaining admission to later, Wolf8 echoes this worry, adding a students. He recommends that calculus, medical school requires a different kind comment about the types of minds organic chemistry, and physics be of capital: an undergraduate education, created by too much science: dropped from the required curriculum, including high marks in biology, which would open up six semesters for chemistry, and physics, extensive My concern is that we not only are potentially more useful courses in extracurricular and volunteer activities, bringing into medical school young men statistics, genetics, molecular biology, and a high score on the MCAT. and women who lack a civilizing biochemistry, general ethics, and human background in the humanities, who have psychology. In a nod to the other As one would expect, in the nearly 100 read little and may have written not at all, but also we are making medical school varieties of criticism, he adds that his idea years since Flexner’s report, there has admission easy for concrete thinkers, of a new curriculum would give students been disagreement about the content of a those who know how to learn only if the extra time to “pursue other interests in “rigorous” premedical education. Review material to be learned is clearly laid out. this formative period, ensuring they of these disagreements reveals three types [receive] a true liberal education.”11 of critics: those who argue for eliminating Critics of this stripe fear that science a defined premedical curriculum, those courses tend to crowd out work in Although Emanuel’s recent and rather who believe premedical education is humanities and the human sciences. radical suggestions for reform generated 9 important but worry that it has become Gellhorn writes: some support,12 they also brought a too focused on the sciences, and those In order to give the committed chorus of voices raised in defense of the who call for constant vigilance in keeping premedical student time for a broad current premedical requirements. the premedical curriculum up-to-date so education in the humanities and social Kramer13 defends that bane of the that students will be properly prepared sciences, it is necessary to eliminate those premed—organic chemistry: “I would for the new science and business of courses which are not contributory . . . not so hastily dismiss organic chemistry medicine. and to revise the course material in as a mere tool to thin the applicant herd. mathematics, chemistry, biology, and Indeed, I believe that no other premedical physics so that it is directly pertinent to 6 Lewis Thomas is perhaps the best- the biomedical disciplines. course so directly impacts clinical known advocate for eliminating a practice.” Higgins and Reed14 are also separate and clearly defined premedical Sympathy for a “revise, but do not reject” wary about dismissing the value of hard curriculum. His strong belief in the value approach to premedical education is science: “While we agree with many of

Academic Medicine, Vol. 83, No. 5 / May 2008 517 Premedical Education

[Emanuel’s] views, we think it is grade point average. As for their We found a subtle, but important, misguided to exclude courses in organic nonacademic work, premeds organize tension in the nature of this advice. chemistry and physics.” their summer and their spare-time Whereas advisors are aware that the experiences to demonstrate that they are premedical years should both build the kind of caring, curious, involved, and and reflect the character of the next What’s Missing? dedicated people that medical schools are generation of physicians, they cannot After 100 years of debate, we are not any looking for. help being strategic in their advice to closer to understanding what may or may students. There exists a continuum of not be wrong with premedical education. Students learn how to manage their advice giving. On one end of this As we noted above, the century-old premedical years by listening to advice continuum is the strategic—“you discussion is remarkable for its lack of given from a variety of sources. Books, must do this to satisfy the admission attention to the lives of premedical Web sites, relatives, friends, and health committee”—and on the other end there students. The tradition of complaint professionals stand ready to supply is advice on creating character—“do this about premedical education that extends information on what one must do to get to develop the kind of character that will from Flexner (1910) to Emanuel (2006) into medical school. Aware of the need make a good physician.” ignores the fact that the premedical years for guidance in the process of preparing do more than fill the heads of future for and applying to medical school, most Fine gradations in language distinguish physicians with knowledge. The undergraduate schools have designated advice on “how to build one’s character” requirements established by medical premedical advisors and prepared Web from the more instrumental “how to school admission committees and the sites that offer lists of resources, links to impress an admissions committee.” For courses and tests used to “weed out” various medical school admission- example, with regard to nonscience those who are not “qualified” to become oriented Web sites, and answers to the courses, students at MIT are told, rather physicians do more than lay the frequently asked questions of premeds.16 directly, “A number of medical schools groundwork for the rigors of medical also require classes in behavioral and school—they also create a premedical Advice on how to succeed social sciences,”18 whereas at Yale, student culture with a distinctive set of To better understand the type of advice students learn that “all schools recognize norms and values. One does not have to that premeds receive, we looked at the the desirability of a strong foundation in believe in the existence of the “premed premed-oriented Web sites of a stratified the natural sciences . . . and a solid syndrome”15—excessive concern with random sample of undergraduate background in the social sciences and grades, extreme competitiveness, and lack colleges and universities. Using the 2007 humanities.”19 MIT simply advises of sociability—to acknowledge that rankings of colleges and universities done students that these courses must be on during the premedical years, students by the U.S. News and World Report,17 we their transcript, whereas Yale gives a nod learn more than information from their selected a stratified random sample of 40 to the value of a “solid background in textbooks and teachers. During their colleges and 40 universities from the four social sciences in the humanities.” undergraduate years, the physicians of “tiers,” choosing more from the first and tomorrow learn how to learn and how to second tiers. We found 35 usable Web Should premedical students get involved succeed in the contest for admission to sites for universities and 34 usable Web in research? The University of Virginia medical school. sites for colleges. Between January and tells premeds that doing research will March 2007, two researchers combed “demonstrate in-depth, sustained these 69 Web sites looking for the scholarly exploration, as well as the Thinking Like a Premed resources available to premeds and the presence of lifelong learning skills, that When medical schools review applicant kinds of advice they were given regarding are essential in these professions”20 dossiers, they rightly want to know one how to succeed in gaining admission to (emphasis added). Notice that premeds thing: does this student have what it medical school. are not told that research will develop takes—the intellectual ability and the these qualities; rather, the advice is geared character—to succeed and become a The majority of these Web sites offer toward the strategic goal of demonstrating competent and caring doctor? For their practical advice on the courses one character. Similarly, premeds at Iowa part, premedical students ask, “How do I should take as an undergraduate, direct State are told of the strategic value of present myself so that an admissions students to local resources (premedical extracurricular activities: “Extracurricular committee will see that I have what it clubs, meetings, lending libraries), and activities that focus on leadership and takes?” explain local procedures (the role of the community service have become VERY premedical committee, the scheduling of important for admission, especially to As they navigate their way through the mock interviews, the requirements for a medical school. Get involved!”21 undergraduate years, premeds learn how committee letter). Given our focus on the (emphasis in original). to manage both the academic and experience of premeds, we looked most nonacademic portions of their resumes. closely at the nature of the advice on how Advice about the value of volunteer work With regard to academics, premeds to put together a competitive medical is much the same. At Wittenburg College, choose courses that are required by school application. In particular, we students are told: “Volunteering two to medical schools and that are necessary to looked at what students are told three hours each week during the perform well on the MCAT. On the other regarding nonscience courses, volunteer semester demonstrates to the schools hand, they avoid courses that, although work, and involvement in research and your loyalty and commitment to the interesting, may lower the all-important extracurricular activities. profession.”22 At Swarthmore: “If you

518 Academic Medicine, Vol. 83, No. 5 / May 2008 Premedical Education volunteer either during the school year or clinical and research experiences would implicated in the development of an the summer in health care related look good on their application, and applicant’s noncognitive attributes, both facilities, it shows you are motivated and cultivating relationships with professors positive and negative. committed to helping people. It also in order to get positive letters of demonstrates to medical school reference. On the basis of our research and admissions committees that you have observations, we suggest a new approach seen firsthand what a medical setting is to premedical education—an approach like.”23 The emphasis is on the strategic— Rethinking the Premedical Years that not only provides the nuts and bolts medical school applicants must “show” The premedical years are a vital yet of recommended coursework and or “demonstrate” their character. understudied part of the process of necessary preparation for the MCAT but becoming a doctor in the United States. that also gives students the opportunity Journey or tourney? Those who call for the reform of to step back and reflect on the path to a We realize the subtle nature of the premedical education focus almost career in health care. Students must distinction between developing a trait exclusively on the content of the courses, realize that the undergraduate premedical and demonstrating it. However, it is a ignoring the many lessons learned by experience is not just a means to enter distinction that reflects a social process premedical students as they prepare their medical school; it is also an experience whereby experiences that were meant to applications to medical school. The that is shaping their character. The best be a way to check a student’s character premedical experience gives students a way to help premeds understand the become nothing more than “boxes to be moral education, showing them what it influence of the hidden curriculum checked” when putting together a takes to succeed, and thereby creating the is not another class on ethics or medical school application. To translate character of our next generation of professionalism. What is needed is a what we were reading on the Web to the physicians. course that encourages students, early in lives of premedical students, we convened the premedical careers, to reflect on their a half-day symposium on premedical Medical educators see the teaching of motives for choosing to become a education in Ann Arbor, Michigan, in ethics and professionalism in medical physician, to recognize the influence of April 2007. The 27 attendees included school as an important way to ensure that premedical culture on their behavior, and premedical students, (10) first- and second- physicians in the United States are to understand the difference between the year medical students, (9) premedical compassionate, competent, and ethical. demonstration and the development of advisors, (4) and medical school However, we believe that this teaching character. admissions committee members (4) from comes too late in the student’s training. When students and their advisors are five universities in the Midwest. We The moral education of a physician aware of the ways that the premedical presented our research on critiques of begins in the premedical years (or years are both a journey and a medical education and on advice to premeds, perhaps even earlier as middle school competition, they will see the positive and, using breakout groups, we solicited and high school students develop and pernicious influences of the way we comments from the attendees about their strategies for admission to the “best” in the United States select our future perceptions of the premedical years. undergraduate institutions). By the time a student reaches medical school, he or physicians, and they will be better We discovered that the “strategic/creating she has already learned how to learn and equipped to become and to create “good” character” continuum tracked closely how to succeed, often by demonstrating doctors—in both senses of that word. with differences in how students and character as a shortcut to developing it. administrators perceive the admissions Acknowledgments process. Several premedical advisors and Our review calls attention to the blind This work was supported by a grant from the medical school admissions committee spots of those who believe that reform of President’s Initiative on Ethics in Public Life at members described the path to medical premedical education requires only the University of Michigan, the Department of school as a “journey” where the demands altering the content of course material. Medical Education, and the Bioethics Program at of the premedical years helped students There is a need for more research on the University of Michigan Medical School. The discover their fit with a career in what students learn from the experiences authors report no conflicts of interest. medicine and/or with the characteristics of the premedical years and the influence of different medical schools. Most of these experiences on the ethical References students did not accept this metaphor, behaviors of future health care 1 Hafferty FW. Beyond curriculum reform: describing their premedical years more as professionals. Whereas various authors Confronting medicine’s hidden curriculum. a competition than as a journey. They have demonstrated the importance of Acad Med. 1998;73:403–407. saw the premedical years not as a voyage evaluating “noncognitive” attributes of 2 D’eon M, Lear N, Turner M, Jones C. Perils of self-discovery but as a set of obstacles students seeking admission to medical of the hidden curriculum revisited. Med to overcome on the way to the elusive school24–25 (with some even going as a far Teach. 2007;29:295–296. 3 Finder A. 34 Duke business students face goal of medical school admission. Taking as offering techniques for identifying discipline for cheating. New York Times. May their cue from the strategic advice they “cunning” applicants, who “have a 1, 2007:A15. had been given, they carefully planned chameleon-like ability to adopt the short- 4 Association of American Medical Colleges. their undergraduate years—avoiding term personality of ‘Mother Theresa’ and FACTS—Applicants, Matriculants and Graduates. 26 Available at: (http://www.aamc.org/data/facts/ classes that may have been helpful to a the career interest du jour” ), no one start.htm). Accessed January 23, 2008. future physician but might harm their seems concerned with understanding 5 Flexner A. Medical Education in the United grade point average, calculating which how premedical education may be States and Canada. A Report to the Carnegie

Academic Medicine, Vol. 83, No. 5 / May 2008 519 Premedical Education

Foundation for the Advancement of 15 Conrad P. The myth of cut-throats among career.virginia.edu/students/preprof/prehealth/ Teaching. Bulletin No. 4. Boston, Mass: premedical students: On the role of extra.php). Accessed January 24, 2008. Updyke; 1910. stereotypes in justifying failure and success. 21 Iowa State University. Preparing for health 6 Thomas L. The medusa and the snail. N Engl J Health Soc Behav. 1986;27:150–160. professions. Available at: (http://www.las.iastate. J Med. 1977;296:1104. 16 Stanford University Premedical Association. edu/academics/prehealth/preparing.shtml). 7 Reinke EE. Liberal values in premedical Getting started: FAQs. Available at: (http:// Accessed January 24, 2008. education. J Assoc Am Med Coll. 1937;12: www.stanford.edu/group/spa/faqs.html# 22 Wittenberg University. Allopathic Medical 151–156. three). Accessed January 23, 2008. School: Doctor of Medicine (M.D.). Available 8 Wolf SG. “I can’t afford a B.” N Engl J Med. 17 U.S. News and World Report. America’s Best at: (http://www4.wittenberg.edu/academics/ 1978;299:949–950. Colleges. Available at: (http://colleges.usnews. pre-health/Allopathic/text.html#e). Accessed 9 Gellhorn A. Letter: Premedical curriculum. rankingsandreviews.com/usnews/edu/college/ January 24, 2008. 23 Swarthmore College. Guide to Premedical J Med Educ. 1976;51:616–617. rankings/rankindex_brief.php). Accessed January Studies at Swarthmore College. Available at: 10 Page RG. Impact of changes in premedical 24, 2008. (http://www.swarthmore.edu/x8886.xml). education on medical education. J Med Educ. 18 Massachusetts Institute of Technology. MIT Accessed January 24, 2008. 1968;43:717–723. recommended premedical course list. Available 24 Reede JY. Predictors of success in medicine. 11 Emanuel EJ. Changing pre-med requirements at: (http://web.mit.edu/career/www/preprof/ Clin Orthop Relat Res. 1999;362:72–77. and the medical curriculum. JAMA. 2006; medadmissions.html#extra). Accessed January 24, 25 Peskun C, Detsky A, Shandling M. 296:9:1128–1131. 2008. Effectiveness of medical school admissions 12 Collier V, Smith L, Weinberger S. Changing 19 Yale University. Information for premedical criteria in predicting residency ranking four premedical requirements. JAMA. 2007;297:38. students. Available at: (http://www.yale.edu/ years later. Med Educ. 2007;41:57–64. 13 Kramer DB. Changing premedical yalecollege/freshmen/academics/premedical/ 26 Albanese MA, Snow MH, Skochelak SE, requirements. JAMA. 2007;297:37. index.html). Accessed January 24, 2008. Huggett KN, Farrell PM. Assessing personal 14 Higgins TS, Reed SF. Changing premedical 20 University of Virginia. Prehealth: Volunteer, qualities in medical school admissions. Acad requirements. JAMA. 2007;297:37. research programs. Available at: (http://www. Med. 2003;78:313–321.

Teaching and Learning Moments It’s Okay Not to Know “I don’t know” isn’t usually the best offered individual views about abortion can’t resolve it, how can I? Does that answer a teacher gets from a class, but and, as often happens, the talk turned make me a bad student? Will it make one morning in tutor group where the to the question of when life begins. The me a bad doctor? Or is it good I topic was abortion, it stood out from statements were easy to predict, with “at recognize a complex problem? I just the rest. conception” or “at implantation” leading don’t know when life begins.” the pack, often accompanied by labels of Abortion is always a tricky subject to “of course” and “unquestionably.” I was reminded of a quote from discuss as logic, medicine, law, and William Cowper (1731–1800): emotion quickly intertwine. In our first- But an unusual answer came from one “Knowledge is proud that it knows so year curriculum medical students are of the quieter members of the group much; wisdom is humble that it knows encouraged to follow the self-directed when she said, “I don’t know.” The rest no more.” I shared the quote with the learning path espoused by problem- of the group turned to her, astonished. based learning. They explore new “I don’t know when life begins,” she group for discussion and one student, medical and scientific topics with zeal, added quietly, “and I’m amazed that an English major, responded with but they carry with them the framework you are so absolute about your another Cowper quote: “Where men of their religious and/or social belief answers.” She had earlier said she of judgment creep and feel their way, system. Many of them are still young accepted abortion as self-defense, saying the positive pronounce without enough to think that others in their peer if a woman’s health was in danger she dismay.” The talk turned to when group (medical students) will think like could see grounds for abortion, but physicians can say “I don’t know” to them on The Big Topics, like abortion another group member had jumped in their patients and not lose patient and euthanasia, and they can be with their opinion and she had offered trust, and, for the first time in the surprised, perplexed, and sometimes nothing more. Now she put her hands month the group had been meeting, horrified by what others believe. on the table in front of her, fingers the quiet young woman eagerly led spread, then slowly slid them back to her the way. That morning in tutor group we found lap, a gesture she often used when ourselves discussing abortion, and the unsure, but inquisitive, and added softly, Sandra L. Shea, PhD classic arguments soon crowded the “This question has been debated for table as students rushed their ideas centuries by lay people as well as by Dr. Shea is associate professor, Department of forward. Eventually the students doctors, lawyers, politicians, and Family and Community Medicine, Southern Illinois acknowledged their differences and religious men and women, and if they University School of Medicine, Carbondale, Illinois.

520 Academic Medicine, Vol. 83, No. 5 / May 2008