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.