AAMC Reporter: April 2008

A Word from the President: "The Gateway To Being A Doctor: Rethinking Premedical Education"

This month, as high school seniors nationwide receive their college acceptance letters, a new generation of premedical students approaches our profession's gateway. But when they arrive, will some feel limited or even discouraged by certain course requirements? And when they later apply for medical school admission, will we have the tools necessary to help us better appreciate and holistically consider each student's unique set of credentials?

Though we have worked diligently to rethink other parts of the medical education continuum, our fundamental approach to premedical education has remained largely unchallenged and unchanged for decades. If we turn our attention to this first and critical step to becoming a doctor, a number of important questions arise.

First, how do we define the core educational foundation every premedical student should have?

The larger and more rigid the premedical core requirements, the less we encourage heterogeneity among students and innovation by college faculty. Our goal should be to provide students the greatest amount of flexibility, while ensuring they are prepared for early work in medical school.

For example, the heavy weight placed on the physical sciences, coupled with year-long course requirements,may have the effect of driving students toward certain premedical majors. Like generations before them, the 2007 entering class included far more students who majored in the biological sciences than in the humanities or social sciences. Further, we frequently hear from college professors who feel that these requirements limit their ability to adopt new, integrative teaching approaches.

In addition to providing greater flexibility, we also must consider whether current premedical education requirements—some a century old—"fit" with how basic science and medical practice have changed. Given the recent explosion in medical knowledge, emergence of new areas such as genomics, and our growing reliance on multi-disciplinary approaches to patient care, is adherence to the traditional premedical formula appropriate for every student?

These are just a few of the questions the AAMC is exploring through two initiatives. One is an interprofessional collaboration with the Howard Hughes Medical Institute to define the spectrum of basic scientific competencies every doctor should master, and the other is a Medical School Objectives Project that focuses on integrating the behavioral and social sciences as part of this spectrum. Given what we know about today's medical school matriculants, are we maximally encouraging of premedical students who have pursued atypical pathways?

All of us are familiar with medical students who "knew" as youngsters they wanted to be doctors and declared themselves "premed" as college freshmen. However, as one who decided very late in college (as a philosophy major) to pursue medicine, I often have wondered whether our profession has been as welcoming to others who took "atypical" pathways. And while I always have believed our learning environments benefited from this diversity of perspectives and experiences, I am more convinced than ever that our patients do as well.

For example, given the increasing number and complexity of ethical issues we face, might we be more encouraging of students who major in the humanities, philosophy, or even religion and want to join our ranks? Considering the role information technology increasingly plays in medical practice,might we more actively recruit computer science and engineering majors to pursue medicine?

Additionally, have we made medicine as accessible as possible to those who have spent significant time after college working in the "real world," but suspect that medicine is their true calling?

Does the MCAT™ test all that we want it to test? The MCAT does an excellent job of what it is intended to do—measuring the science knowledge and analytical skills needed to do well in medical school. And though it was not intended to measure the equally essential noncognitive skills (e.g., cultural competence, selflessness), we continually hear discussion about the need to better assess these attributes as part of the admissions process. Perhaps the time has come to invest in developing new instruments that could be administered along with the MCAT or used by admissions committees as part of a toolkit. What resources do we have beyond the MCAT to help select our applicant pool?

Anyone who has served on an admissions committee knows we tend to rely heavily upon letters of recommendation. Generally, these letters consist of evaluative comments made by faculty who know the applicant within a limited context. Rarely do these letters tell us, for example, how a student handled great loss and became more empathic, worked through a difficult situation and developed better judgment, or discovered the motivation necessary for a lifetime of learning and continuous self-assessment.

Rather than relying on undifferentiated letters of recommendation, we might consider using alternative resources, such as a behavioral form already in use. Using this form, each recommender rates students on key characteristics, and then substantiates their ratings with behavioral observations.

How should medical school applicants and admissions committees come to regard the overall process of entry to medicine as a profession?

As we begin to rethink our requirements and processes in selecting students for medical school, we must also develop a portfolio of resources to help better appreciate each student's unique mix of experience, perspective, and character. This is the "holistic" approach to admissions that is generating considerable interest in our community. A new multi-year AAMC project, which is developing tools to support medical schools' holistic review practices, is a key step toward these goals.

In summary, just as we are working to improve the phases of medical education that follow acceptance to medical school, it is essential we apply the same degree of energy to premedical education. Whether the newest generation of premedical students finds medicine's gateway a narrow entry through which they must fit in a stereotypic manner, or an open passage which is more willing to acknowledge their own individual journey, is up to us.

Darrell G. Kirch, M.D., AAMC President and CEO

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