Questioning the Premedical Paradigm Barr, Donald A. Published by Johns Hopkins University Press Barr, Donald A. Questioning the Premedical Paradigm: Enhancing Diversity in the Medical Profession a Century after the Flexner Report. Johns Hopkins University Press, 2010. Project MUSE. doi:10.1353/book.462. https://muse.jhu.edu/. For additional information about this book https://muse.jhu.edu/book/462 [ Access provided at 1 Oct 2021 20:42 GMT with no institutional affiliation ] This work is licensed under a Creative Commons Attribution 4.0 International License. Questioning the Premedical Paradigm This page intentionally left blank Questioning the Premedical Paradigm Enhancing Diversity in the Medical Profession a Century after the Flexner Report DONALD A. BARR, M.D., PH.D. Associate Professor Departments of Sociology and Pediatrics Stanford University Stanford, California The Johns Hopkins University Press Baltimore © 2010 The Johns Hopkins University Press All rights reserved. Published 2010 Printed in the United States of America on acid-free paper 24 6897531 The Johns Hopkins University Press 2715 North Charles Street Baltimore, Maryland 21218-4363 www.press.jhu.edu Library of Congress Cataloging-in-Publication Data Barr, Donald A. Questioning the premedical paradigm: enhancing diversity in the medical profession a century after the Flexner report / Donald A. Barr. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8018-9416-9 (hardcover : alk. paper) ISBN-10: 0-8018-9416-6 (hardcover : alk. paper) 1. Premedical education—United States. I. Title. [DNLM: 1. Education, Premedical—United States. 2. Cultural Diversity— United States. 3. Physicians—United States. W 18 B268q 2010] R838.B37-2010 610.71Ј173—dc22 2009020308 A catalog record for this book is available from the British Library. Special discounts are available for bulk purchases of this book. For more information, please contact Special Sales at 410-516-6936 or [email protected]. 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For Isaac This page intentionally left blank contents Preface ix Introduction 1 1 Who Drops Out of Premed, and Why? 11 2 The Historical Origins of Premedical Education in the United States, 1873–1905 35 3 A National Standard for Premedical Education 55 4 Premedical Education and the Prediction of Professional Performance 82 5 Noncognitive Factors That Predict Professional Performance 108 6 Efforts to Increase the Diversity of the Medical Profession 135 7 Nontraditional Programs of Medical Education and Their Success in Training Qualified Physicians 157 8 Reassessing the Premedical Paradigm 172 9 Another Way to Structure Premedical Education 185 Notes 199 Index 221 This page intentionally left blank preface This book has grown from my experiences advising undergraduates at Stanford Uni- versity over a period of fifteen years. In that time I have seen many fine, fully qualified students enter Stanford with the aspiration of becoming physicians and leave Stan- ford to enroll in medical school as the fulfillment of that aspiration. However, I have also seen similar numbers of students, most of whom also appear fully qualified, enter as premedical students only to drop medicine as a possible career. I felt both a per- sonal and a professional need to find out why some students stayed in premedical studies and others left. The research I initiated to explore this issue was the genesis of this book. In chapter 1 I describe the results of research I conducted over a period of five years, following students entering either Stanford or the University of California, Berkeley, with a self-identified interest in becoming a physician. The results confirm my initial impression and raise an important issue. Courses in chemistry, biology, and physics, the same triad that seemed to define the “purpose of life” for premedical students when I was in college more than forty years ago, apparently serve that same function today. Where did this come from? What were the historical origins of this belief in the predictive value of success in chemistry, biology, and physics? I address this question in chapters 2 and 3. In chapter 2 I trace the historical roots of premedical education from the late 1800s through 1905, the year our current model of premedical education was explicitly de- fined by the recently established Council on Medical Education (CME) as the norm by which medical schools should be judged. Following that action by the CME, a principal goal of medical educators was to ensure that students entering medical school had an adequate grounding in the fundamental principles of chemistry, biol- ogy, and physics. As we will see, the growing focus on premedical success in these subjects was based on a combination of political necessity and commonly held belief, with little in the way of scientific evidence linking premedical success with clinical x Preface success. Chapter 3 extends this analysis by following the historical evolution of pre- medical education from 1905 onward, through the reports from the 1920s of the need to avoid “wastage” (i.e., academic failure in the first year of medical school) among medical students, to a 1953 report that explicitly identified the necessity of “weeding out” less-qualified premedical students early in their college careers. To what extent does success in the premedical sciences actually predict success in medical school and success as a clinical practitioner? I address this question in chapter 4, reviewing several decades of studies linking metrics of success in the premedical sci- ences with success in medical school and success in clinical practice. What we will find is that modeling the cause/effect associations between premedical success and success in and after medical school is complex. Some of the associations are as might be ex- pected; some are unexpected. The message we will derive from these studies is that like begets like. Success in the premedical sciences gives rise to success in the preclinical sci- ences encountered early in medical school. However, the data repeatedly demonstrate that success in the premedical sciences has little predictive value regarding eventual success as a clinician. A substantial shift occurs midway in the medical school experi- ence, from a focus on acquiring scientific knowledge to a focus on acquiring clinical knowledge and learning how to apply that knowledge in an actual clinical context. After this shift takes place, the role of success in the premedical sciences diminishes as a predictor of success in medical school. If scientific knowledge is linked only loosely with clinical skills, are there other fac- tors that might accurately predict clinical success? As described in chapter 5, this is a question medical educators have been struggling with for more than fifty years. There is an extensive series of studies on the psychological, or “noncognitive” aspects of pre- medical preparation and medical practice that parallels the studies described in the previous chapter focusing on the scientific, or “cognitive” aspects of premedical prepa- ration in the sciences. From the period preceding the Flexner Report of 1910 to the present, medical educators have approached the practice of medicine as part science and part art. If success in the premedical sciences predicts success in the science of med- icine, what (if anything) predicts success in the art of medicine? As we shall see, the answer to this question has proved to be elusive. In his 1910 report, Abraham Flexner was concerned with the scientific basis of med- ical education and medical practice. He had little to say about the racial or ethnic di- versity of the medical profession. Today the issue of diversity within the medical pro- fession is central to medical education. A series of reports from organizations such as the Institute of Medicine of the National Academy of Sciences, the Association of American Medical Colleges, and the Office of the President of the University of Cal- ifornia have underscored the urgency of increasing the racial and ethnic diversity of Preface xi the medical profession as a national policy priority. In chapter 6 I review efforts from the 1960s onward to bring more students from underrepresented racial and ethnic mi- nority (URM) groups into the premedical “pipeline” and help them prepare for med- ical school and a career as a physician. Will adopting programs that make medical education more available to URM stu- dents necessarily imply a lowering of standards for entry into the medical profession? Chapter 6 goes on to review a series of studies that address this question. The data will confirm what we have discovered at Stanford: URM students often have a more dif- ficult experience in the premedical sciences. However, more than two decades of re- search in the academic and career trajectories of students who enter medical school through programs of affirmative action or other programs designed to increase URM participation in medical education show conclusively that little if anything is sacrificed by making medical education more available to these students. In a landmark study from the University of California, Davis, students admitted under the system of racial and ethnic preferences that were eventually outlawed by the Supreme Court’s Bakke decision demonstrated markers of professional success that were largely indistinguish- able from their classmates who gained admission through the classical premedical cur- riculum. While Flexner’s model of premedical education continues to be the norm nation- ally, a number of medical schools have adopted alternative approaches to admissions. I review some of these in chapter 7. In particular, the medical school at McMaster University in Canada, has made admissions available both to students who are pre- pared in the premedical sciences and those who are not.