The Science of Medical School Admissions

I saw an article in the paper a couple weeks ago about how the medical school at Brown University had begun admitting a small number of students each year without requiring them to take the usual premedical science requirements or the Medical College Admission Test (MCAT, commonly pronounced either “em-cat” or “night-mare”).  This comes as quite a revelation to me but not really much of a surprise.

To get a feel for the world of the premedical student all you have to do is spend an evening in the science section at the library of your nearest 4-year university.  There you’ll find a horde of students pouring over their microbiology and physics textbooks, fretting over the next organic chemistry test, and plotting ways to talk their professor into switching their latest B+ to an A-.  They’re the ones who will toss their classmates under the bus if it means they end up with a slighter higher standing in their zoology class.

There’s actually no such thing as a pre-med major (contrary to what many college freshmen may claim in a futile effort to enhance their social life), just a pile of courses that all medical schools require of each student hoping to become a doctor.  Everyone who ends up going to medical school has graduated in some subject and most stick to the sciences: biology, zoology, biochemistry, physics, etc.  That makes sense: it’s easier to survive college and the pre-med requirements if your major already encompasses most of the 32-some-odd credits of necessary study.

A much smaller fraction of premedical students spend their college days outside the science buildings.  I found the environment of the premedical world rather suffocating, but for reasons other than being surrounded by the highly-competitive doctor-wannabes—I simply didn’t like biology and chemistry all that much.  Add to that the pressure of having a father who was a renowned anatomy professor at the same university I attended (all the instructors of the pre-med courses were members of his department and expected nothing short of brilliant perfection from his son) and it was enough to drive me straight to the humanities building.  I spent the last two years of my college days analyzing Goethe, Lessing, and Schiller in the German department and far from the pre-med pressure cooker.

My choice in major came back to haunt me the day I took the MCAT.  As it was administered in the eighties (it has since be reworked) it was a punishing 12-hour grind that was somewhat like waterboarding but with less day-spa ambience.  The test focused on every detail of physics, calculus, chemistry, and biology imaginable.  Curiously, the sadistic writers of the test seemed far less interested in the lyrical prose of Rilke or the novels of Heinrich Böll than in the lifecycle of the typical tapeworm, and thus I found myself at a distinct disadvantage to my fellow science-majoring students.  I recall walking out the testing center that day vowing that if my MCAT score proved inadequate I would rather abandon my aspiration of medical school than to ever submit to that test again.

Well, I don’t recall my score, but it must have been high enough to land me a few interviews.  Being from Utah I was very interested in attending the University of Utah in Salt Lake City and was assigned interviews with two senior medical professors.  The first, an anesthesiologist, zeroed in on my German major immediately and expressed concern about my apparent lack of a solid science background.  From there things went downhill and it became quickly apparent that a grade-schooler at a science fair looked more like his ideal of the perfect medical student than I did.

My second interview was with an aging neurologist who also began by commenting on my choice of undergraduate study.  He asked me to defend my decision to major in a language rather than in biology like most everyone else.  By that point I knew I had no chance of spending my medical school years in Salt Lake and subsequently began to be less anxious.  Calmly, I replied that a humanities major allowed me to explore a broad spectrum of knowledge before I was consigned to 4 years of strict scientific study; that literature in particular enabled me to have a better understanding of human nature; and that the skills I’d learned in literary interpretation could prove to be useful in future communication with patients.

He smiled when I finished and to my surprise settled in to tell me his own story.  Years earlier he’d been the only member of his incoming medical class to have not graduated in a field of science and that his choice of Latin as a major had provoked considerable discussion among the members of the admissions committee.  Reluctantly they admitted him to the school but on the condition that he actually perform better than his classmates during the first year of basic science study.  Of course he succeeded and, years later, there he sat explaining to me why he thought I’d fit right in among the members of the matriculating class.

He was right, although for the first few weeks I felt like a fish out of water trying to catch up with my classmates who already had a solid grasp on histology and biochemistry.  People sometimes say that the first two years of medical school is a lot like trying to get a drink by putting your mouth on a fire hydrant—the volume of information is simply staggering—and I’ll admit I struggled to survive.  The last two years of medical school had us spending time in the hospital wards and clinics and it was in that environment that we began to figure who among us would become successful doctors.  One thing became quickly apparent: there isn’t much correlation between getting high scores in the basic sciences and succeeding in the clinical environment.  Sure, a solid understanding of anatomy, physiology, and pathology were indispensable and no student, no matter what kind of wonderful bedside rapport they may have had, succeeded without a stable foundation of medical knowledge.  My experience at the time—and this has been validated for me as I’ve progressed through my career—was that the best measure of a quality physician was not his or her scores on biochemistry tests.

Yet MCAT scores and grade point average in the basic sciences are the only objective parameters medical admissions committees have to filter the thousands of applicants that line up at their doorstep.  A student who could potentially become a great doctor won’t make it past first base if he or she can’t perform adequately in physics and chemistry, unless they apply to this year’s class at the prestigious Brown University, of course, where they might gain entrance without ever having to submit to the MCAT.  You may think that with my Bachelor of Arts (rather than Science) I would be solidly in favor of such an evolution but I confess that I have mixed feelings.

It is apparent to everyone in the medical establishment that we need doctors who can do more than just regurgitate scientific facts and formulas.  For years medical schools have been looking for ways to include in their applicant assessment a way to tease out the “humanism” in potential students.  The MCAT has been restructured to incorporate an essay section that requires students to ruminate on subjects more subjective than the Krebs citric acid cycle.  Most schools now put far greater emphasis on the interview process than on grade point average.  With studies showing medical school academic performance is similar for students with a humanities background (or arts, music, etc.) and those reared in the sciences, many schools actually try to recruit applicants who have a more varied resume.

What’s also needed, though, are students who can master the massive volumes of information needed to practice medicine in today’s technological age.  Recall the analogy of the fire hydrant and remember that the knowledge encompassed in the world of medicine doubles every few years; yet despite this medical school remains fixed at only 4 years—just like it’s been for 2 generations.  As far as I can tell, being able to succeed in the pre-med classes and pass the MCAT still seem to be the best indicators of those students who will be able to handle the academic rigors of medical training.  A great bedside manner will do you no good if you can’t get through your first year of medical school.

In the end I’m grateful that I majored in German rather than microbiology for all the reasons I spelled out in my medical school interview.  While being able to speak German hasn’t done me much good (unless you count being able to accurately pronounce words like Wenckebach and Trendelenburg), studying Goethe has.  I think medical schools are now reaching a better balance between the hard sciences of physics, math and chemistry and the soft sciences of communication, empathy, and creativity.