• What should premed requirements be?

    As I mentioned earlier, I’m at Amherst College for a few days talking to economics  and premed students. At dinner tonight, one of the things we discussed was how premed requirements seem antiquated and sometimes useless. How many times do physicians really need to call on their two semesters of organic chemistry. This is coming from two chemistry majors (myself and the chair of the economics dept). How timely, then, that the NEJM has a piece directly on poing. “Reforming Premedical Education — Out with the Old, in with the New“:

    The most consistent and strident calls for medical education reform over the past century have focused on premedical preparation. The first attempt at standardizing requirements for medical school admission came in 1904 from the American Medical Association’s Council on Medical Education. In 1910, Abraham Flexner recommended requiring biology, chemistry, botany, and physics, and by 1930, today’s premedical science preparation — biology, chemistry, organic chemistry, and physics — was firmly established. But criticism began as early as 1929, and in 1939 the Association of American Medical Colleges weighed in.

    Recent years have seen many calls for enhancing, overhauling, or abolishing the traditional premed requirements. Critics argue that the pace of scientific discovery and its clinical application have outstripped the requirements; that information technology has made memorizing vast amounts of content unnecessary; that the requirements lack clinical, scientific, and social relevance; that they’re used to cull the herd of talented aspiring physicians; that they disadvantage minority and female students; that they crowd out studies of bioethics, social justice, and health policy; and that rigidly structured premedical and medical school curricula hinder students from becoming self-directed lifelong learners.Furthermore, the current model has perpetuated “premed syndrome,” a culture of aggressive competition for grades that conflicts with the precepts of medical professionalism: academic and intellectual rigor, creative thinking, collaboration, and social conscience.

    I could not agree with this more. Tonight, we discussed how some classes in psychology, philosophy, decision making, and others might be far more useful than physics and chemistry. David Muller has his own ideas:

    academic rigor with less grades-driven competition; independent mentored scholarship; flexibility to pursue widely varied majors; self-directed educational plans that foster lifelong learning; more scientifically and clinically relevant coursework; and more courses instilling an appreciation for medicine’s social, political, and economic contexts.

    Sounds good to me. Can we get this going?



    • These changes make sense from an educational standpoint–assuming one believes thats the main purpose of pre-medical requirements. However, the changes could easily be worse from a sorting perspective (i.e., medical schools are most interested in selecting the ablest students who are most conscientous, hard working, etc.) which I think is part of the reason these requirements have persisted. Even if the requirements are completely arbitrary, if they are really good at discriminating between the horde of qualified (on the surface) applicants, they serve their purpose (theoretically).

      Now, I don’t think the present requirements are amazingly good at sorting (and they clearly are not very educational) so am open to changing them but the courses you are suggesting could easily be worse at sorting between students (i.e., more luck in grading, subjectivity, etc.). Is there any evidence that is the case? I don’t know but if there was, would be a pretty compelling argument…

      • Yes, I agree with this comment, though there is considerable gaming of the current requirements. I went to a small school like Dr. Carroll, where every pre-med student took more or less exactly the same pre-med courses, which was a good arrangement because it could not be gamed.

        I now go to grad school at a large university where there are countless ways to satisfy say, the biology premed requirement. The consequence is that many students seek out the easiest possible course, which is unfortunate for many reasons.

    • Is there any requirement that someone applying to med school has taken statistics (or takes it during med school)? I can’t think of a more relevant subject for someone practicing medicine today.

    • Of all the changes with premed education, or medical education in general I’m not sure that reducing scientific knowledge is the most beneficial.

      As to the premed syndrome. It has to do with money. Physicians in the U.S. are still very well paid compared with other countries. This may change in the future, however limitations in positions and relative job stability does make for cut-throat behavior.

      Because of the differential in salaries between academic and private medicine, it doesn’t really pay to publish it pays to practice and perform procedures.

      But I suppose it depends on where you see medicine going in the future.

      If you take Vinod Khosla’s approach 80% of M.D.s are superfluous and will be replaced by knowledge systems in the near future.

      Modern physicians within the American health system are becoming much less reliant on personal scientific knowledge and more on experts defining flow-charts on how conditions and patients are to be treated. I’m not sure if this is a positive development, as countless times do we see conflicts of interest and unscientific methods ( reducing accounts of negative studies and increasing reporting of positive studies) and co-opted experts.

      The biggest flaw with medical education in the U.S. is that it takes too long to train. IMHO college and medical school should be combined into 6 or 7 years. The first two years should be a combination of humanities and science, with perhaps an engineering class or two to spark the inventiveness of future medical scientists.

      I’d say that I was one of three students who enjoyed statistics class and found it to be enlightening, especially when critically looking at flawed research papers touting the next blockbuster drug.

      Without a scientific background and understanding of statistics, can a physician really determine snake-oil from therapy. Without the humanities, can a physician really help improve the human-condition and all of its myriad complexities.

      What would be a shame is if physicians become like today’s macro-economists, in an ivory tower of models that don’t work in the real world, with no understanding of either the science as a tool or patient care as the most important objective.

    • Wow! I could not disagree more!!! We need doctors to know more about science, not less. Science has always dominated the understanding of disease, but never more than now. If people find science painful, and take it only to get into medical school, how likely are they to teach themselves the waves of new science that will be the basis for practice in the future?

      The primary purpose of a premedical curriculum is to give students the background in science they need to learn about the biochemical machines that are human beings. A secondary purpose is to ensure that people who cannot learn science do not end up in a career where it is impossible to be competent without strong scientific understanding, and where lifelong learning requires them not only to expand their knowledge, but to master new fields that may not have existed when they were in medical school . The weeding out part is unfortunate, but there must be some way to select students when there is still more demand than supply for medical school slots.

      I have yet to see a persuasive argument that philosophy courses contribute anything to medical practice. Psychology might be useful, depending on the field in which someone practices. It might be of little value for a pathologist, for example.

      It is fine to suggest that people need biochemistry. But “biochemistry instead of organic chemistry???” How do you explain biochemistry without organic chemistry? Do you want doctors to understand something about why compounds pass through membranes, about receptor binding, protein folding, rate kinetics? They will be giving patients drugs. Do you want them to understand how they work, and why they cause complications?

      It is great if doctors learn about health policy, but how do you learn economics without calculus?

      I deal everyday with housestaff who are struggling to keep up with the science they need to learn to function. These strugglers are always people who did the minimum, or perhaps slightly more, science as undergrads. They are simply not prepared to function in the new medical world. They will finish their training, and pass their boards, but they will never be good at this. They were doomed from the start because they did not have the background for it.

    • Several comments in quick succession. First, it has been many years since I took biochemistry, and I don’t know if “they” still require everyone to mesmerize all of them *-ases. I will not attempt to defend the classic biochem course.

      However, one cannot begin to understand antigens or receptors unless one understands the stereochemistry of organic compounds. And I can’t see how one could fit that into a 1 year biochemistry class; one must precede this with some kind of organic chemistry class taken before med. school. Which, in turn, makes no sense if one has not learned basic chemistry (I confess I have a thing for sp3 orbitals).

      And, I like the idea of requiring some knowledge, at some of statistics, either before or during med. school.

      HOWEVER, these days, most of the high-end students have taken an AP class in chemistry, so, this requirement is not as onerous as it seems.

    • Regarding the organic chemistry requirement, I think that it is a prerequisite to successfully mastering modern molecular biology. You likely don’t use it while practicing medicine, but you surely use it while *learning* to practice medicine.

      I taught organic to mostly pre-med students many years ago. It was a painful experience for everyone, but the biggest factor in that was the driving need of the students to get an A in every course.

    • I was a high school physics teacher before medicine so I am ambivalent about Aaron’s comment about less chemistry and physics and more psychology, critical thinking etc. I think physicians SHOULD have a good understanding of physics and chemistry…let’s use those disciplines to teach collaboration and critical thinking as well as decision making. Let’s do more to prepare the pre-med student and the med student for the realities of medicine in the 21st century.

    • I was a psychology major as an undergraduate and studied epidemiology and biostatistics after completing residency. I think that some courses in these disciplines could be helpful in clinical practice. My background in psychology helps me to communicate better with patients and peers, and also keeps me humble since I understand a bit about the cognitive errors that can lead to misdiagnosis and wrong treatment plans. My background in statistics helps me sort through the onslaught of new information that bombards clinicians these days.

    • If you want to change how people get into and through medical school, then you have to change everything that comes after it.
      * Why does premed syndrome exist? Because getting in is really hard.
      * Why is getting in really hard? Because there are limited number of seats.
      * Why is there a limit to med school seats? Because residencies are limited.
      * Why are residencies limited? Because that’s how much money there is.

      The causal flow is backward through residency, med school, and premed. If you don’t like the foundation a building sits on, then make sure you like the building that sits on it first before you start changing the foundation to only later realize that the building is hideous. I know you know exactly what kind of healthcare system we have, and I don’t recall any posts of the tune “yup, I have nothing to say or criticize today.” With that said, arguing psychology vs. organic chemistry seems like an incredible waste of time.