Our current pre-medical education system needs a serious revamp

The pre-med game is rife with unjustified barriers to entry and do not prioritize competencies needed for the profession

A few weeks ago, I wrote a post on the flaws of the medical school pre-clerkship curriculum design and I figured I’d extend this discussion to an area that possibly matters even more - the pre-medical education system.

The time spent in college as a pre-med is arguably the toughest part of the medical journey. With thousands each year vying for the limited number of seats at American medical schools, applicants in today’s day must not only prove excellence in academics, but are also expected to be heavily involved in extracurricular activities and and have some research under their belt. Nothing is set in stone yet career-wise which raises the stakes compared to a medical student or resident. The fact that admission to medical school has become more competitive each year is certainly not helping. The pre-medical pathway has unfortunately remained in the Stone Age, untested with randomized research and with most requirements staying the same over the past few decades. We do not know if our system is truly picking the best among us to become doctors and how it can be optimized. I will dive into a few points here.

Let’s start with the required classes - generally 1-2 years of biology, 1 year of chemistry, 1 year of organic chemistry, and 1 year of physics at the bare minimum. While these are certainly valuable disciplines to learn for many science students, much of the content that is covered is not relevant to the study or practice of medicine. I can potentially see an argument for biology and biochemistry, but I struggle to see how the science behind parallel plate capacitors, nucleophilic substitution reactions, or the kinetics behind balls rolling off of ramps are in any way relevant to being a doctor.

Many of these topics students will never touch once after they are admitted to medical school. All of my college course material and MCAT books continue to gather dust on my bookshelf. This content is so impractical that if you ask 100 medical students, 100 residents, 100 fellows, and 100 attendings to answer college or MCAT-level questions in any of these disciplines, I am sure that you will see decreasing scores as you move on further in training. In comparison, law schools have no course requirements, allowing students to major in and take classes in whatever they like, not necessarily English, Political Science, or History.

Instead, more emphasis should to be placed on extracurricular activities and how they have shaped an applicant’s path to medicine. And by extracurricular activities, I don’t mean their unpaid research gap year. I have written several posts on why research is overemphasized in medical admissions to no real benefit and how this disproportionally benefits wealthier well-connected students who can afford to take time off to pursue these activities. I will not repeat those sentiments here, but many activities preferred in today’s admissions process are unfounded and contribute to continued elitism in medical school admissions.

Activities with a deep and meaningful connection to service should be prioritized instead. Medicine at its core is a service industry, and I believe that the single best preparation any hopeful can have is by working as a waiter or tutor/teacher. These jobs require you to interact with many different people on a daily basis and cater your service towards a larger goal. In the setting of medicine, this is obviously to help patients heal. In the restaurant or classroom setting, it is to ensure your tables get the correct food in a timely manner or your students improve their math skills. People working these jobs often cater to many clients at one time, are exposed to negative feedback constantly, and require critical thinking and coordination with others (chefs, parents etc). If you have a bad night as a waiter, you can see that reflected in your tips and interactions with your clients. You also know what it takes for people to be satisfied with your service.

But in our current system, a disadvantaged student who waited tables to put themselves through college and served thousands of people is seen as less than a wealthy student who published an paper under the mentorship from a family friend in a predatory journal that will never once be cited.

Now the heavy-hitter: the MCAT. When it comes to standardized tests, I am actually in favor of one. There needs to be some universal standard between colleges. A student performing at an “A” level at one school may be completely different than at another. Johns Hopkins, my undergraduate alma mater, was notorious for suspected “grade deflation” in its pre-med courses and I am sure many “B” students would have been “A” students elsewhere. However, much of the basic science knowledge required to perform on the MCAT is both useless to know for a career in medicine and also not a good predictor of success in medical training. The data on this has borne this out, with only a few studies finding any real predictive value on medical school success, especially past Step 1. The MCAT has repeatedly been found to be a very poor predictor of clinical performance in particular.

Although the content on the MCAT is useless in assessing the correct competencies for future doctors, the competencies that are required to become a good doctor do take a certain level of mental acuity, which should be assessed prior to admission. Medicine is a demanding profession where you will spend your entire life continuing to learn and train as the field evolves. I can imagine two roads by which the MCAT can go down:

First, it can be changed to contain more clinically-relevant knowledge. Think about a Diet Step 1 (or a Step 0) - which does test an overabundance of irrelevant factoids, but at least gets you in the habit of memorizing large amounts of information and answering questions in the style of clinical vignettes, which will be required in all future exams. This would be based on clinical information rather than basic sciences on the MCAT, which have no clinical relevance. The other option is to create a non-medical or even non-science test which can be shown to be a stronger predictor of medical school performance. Think about the LSAT, which is taken for law school admissions. Rather than testing information about the law or about information taught in pre-law courses, this test consists more of logic puzzles and reading comprehension. The LSAT has been shown repeatedly to be an excellent predictor of not only success in law school, but also passing the Bar exam. I would be very interested in seeing some randomized data on if the LSAT is actually superior at predicting performance in medical training than the MCAT.

In medicine, our admissions testing should strive for similar goals, and has gone too long without being challenged with rigorous study. For researchers interested in advancing medical education, we are failing to meet this clear need. As it stands, the MCAT continues to be a largely unjustifiabe and costly hurdle that increases the barrier to entry to medical school.

Much of this change begs the question on how much value an undergraduate education provides to those aspiring for medical school . The process towards becoming a doctor is expensive and time consuming between attending college and medical school for a combined 8 years before residency. In addition, the US has a ever-worsening physician shortage in nearly every specialty. In many other countries, students enter medical school right after high school, although the length of medical school is extended to 5 or 6 years. For students whom medicine is a calling and they can consider no other career, this type of system can save both time, money, and graduate doctors at a faster pace. I am unconvinced that an extra few years of undergraduate makes a large difference in the quality of the US-trained doctors compared to foreign medical graduates.

As the profession and training in medicine has evolved, so should the pre-medical process. Too much of the system now has become a “game” of checking boxes off of a list - president of an impactless college club, a publication that will never be cited or benchwork, and a high MCAT score on content students will never use again. Our healthcare system has serious issues, most notably diversity and number of providers. A bottom-up overhaul of this archaic pre-medical process will not only help the profession become more accessible, but will also ensure we are truly choosing the best to follow us into medical school.