A casual conversation five years ago leads to an extensive review of premedical and medical school course requirements—and recommendations for change at the national level.
Not long after I came to Yale in 2004, I had a conversation with Tom Pollard, chair of the Department of Molecular, Cellular and Developmental Biology on the central campus. Although not the purpose of our meeting, he happened to mention that premedical course requirements were having a deadly effect on the biology curriculum. Science was leaping forward, but the content of the undergraduate courses, dictated in part by those premedical requirements, was stuck in molasses. Tom asked me, only half joking, when medical schools were going to stop driving undergraduate students away from biology. This comment referred to a conclusion from a report by the National Research Council, Bio2010. While the problem was national in scope, he asked whether Yale could not take the lead in finding a solution. This was followed by meetings with Yale College's Science Council, where we discussed the undergraduate curriculum. One thing then led to another, and I soon found myself co-chairing a committee to address this issue.
The committee, organized by the Association of American Medical Colleges (AAMC) and the Howard Hughes Medical Institute (HHMI), has been exploring ways of ensuring that future doctors get the best possible grounding in science, while at the same time transmitting an excitement about science to potential physicians and biologists. For two years I co-chaired the committee with Sharon Long, dean emeritus of Stanford College and an alumnus of our graduate school, and, along with 20 of our colleagues, we issued a report last month. The report, “Scientific Foundations for Future Physicians,” makes a number of recommendations directed at both the undergraduate and medical school years.
The current course requirements for premedical students impose a certain rigidity on undergraduate teaching that discourages innovation. Moreover, they cover a lot of ground that is not relevant to medicine, and they omit many areas that are relevant. For example, premed students must take biology, general chemistry, organic chemistry, physics, and calculus, but they do not have to take biochemistry or statistics. Some of the questions on the MCAT are irrelevant to medicine.
In addition, the material is often taught to premed students in a general way without reference to its application to biomedical science. An example of this is found in the standard physics course, where mechanics is explained using as an example billiard balls on a pool table, transferring energy and changing their trajectories as they collide. It would be more interesting for future doctors to learn more of the biologically relevant aspects of physics—for example, how magnetic resonance produces an image that can be used to diagnose brain cancer.
Our committee spent time discussing the role science plays in preparing doctors for medical practice, in particular the question of how much science does a physician need to know? Can he or she simply learn how to treat various medical conditions and then follow the established guidelines? Is it enough to know which antibiotic to prescribe or should the doctor also know why it works? We concluded the “why” is just as important as the “how.” At its core, this is an issue of whether medicine is a trade or an art. I believe it is the latter.
We determined that it would improve both undergraduate science education and the teaching of medical students to move away from a system of premedical requirements based on a list of obligatory courses to a system that requires candidates to master certain competencies, both before and during their medical school years. We recommended that specific required courses be eliminated in favor of eight broad scientific competencies that students must master before they enter medical school and another eight during medical school. (For a copy of the report, visit www.aamc.org/scientificfoundations.) So instead of taking a specific mathematics course, for example, students would need to show that they can apply quantitative reasoning to problems and that they know how to navigate large data sets.
We also focused on the value of closer linkages between the physical sciences, mathematics, biology and medicine. We felt it is important to emphasize the relevance of chemistry and physics to undergraduate biology and to demonstrate the interconnection of all the disciplines during the medical school years.
The lack of specific course requirements in college should permit and encourage innovation in teaching and ultimately, I think, encourage more undergraduates to pursue medicine and biology. Students will arrive at medical school with an even set of competencies that will enable us to teach at a higher level and in a more thoughtful way. Medical educators will have more leeway to develop interdisciplinary courses. All of this could produce an atmosphere that is more like that of graduate school education, with small-group teaching, a more thoughtful approach, and less memorization. Medical schools should spend more time teaching the basic biomedical and physical sciences in the context of clinical medicine. This should be done in the first two years by emphasizing clinical relevance in lectures and small-group teaching sessions, and in the clinical years by bringing the scientific basis of disease pathogenesis, diagnosis, and treatment to the bedside.
Yale College Associate Dean for Science Education William Segraves and his colleagues have already made significant improvements to the undergraduate curriculum at Yale, following a 2003 study here of the entire Yale College curriculum. Their work in all aspects of the undergraduate science curriculum may really take off, once they have a freer hand to focus on competencies rather than course requirements.
Our committee’s work coincides with a review of the MCAT by another committee, assembled by the AAMC, and we are hopeful that our efforts will begin to mesh in the next 12 to 18 months. Assuming there is agreement to do so, it will take several years to rewrite the MCAT, and then colleges will need time to prepare their students for the revised test. But one day in the not too distant future, it is possible that aspiring physicians can spend less time worrying about courses whose main purpose is to screen students for acceptance to medical school and more time exploring the ever-more-complex and fascinating world of biomedical science. That is a day we can all look forward to.