Changing Premed Requirements and the Medical Curriculum

A century ago, the American Medical Association created the Council on Medical Education and published the first minimal standards for medical schools and an ideal medical curriculum. Then, the Carnegie Foundation for the Advancement of Teaching funded an evaluation of medical school performance titled Medical Education in the United States and Canada (the Flexner report).¹ While many objected to its highly critical tone, most medical educators endorsed it and implemented significant change.² A major consequence was that the already fading practice-oriented proprietary schools finally died, while medical education was divided into preclinical science training and hospital-based clinical training.

Since Flexner's time, leading physicians and medical organizations have complained about medical education.^{3 - 4} At least 25 reports have proposed reforms in both the methods and content of medical education, including fewer lectures, more case-based learning, earlier introduction of patient interactions, and using simulations, as well as more instruction in social sciences and palliative care.^{5 - 9} There have been even more calls for changes in graduate medical education.⁴ Yet, what is striking is how little the complaints about medical education heard today have changed from 100 years ago.^{2 ,5} The medical profession needs another Flexner report, one that focuses on areas that thus far have been rather neglected: premedical school requirements and parts of the first- and fourth-year medical school curricula.

Ultimately, the Council on Medical Education and the Flexner report were successful because they reinforced the underlying changes in the understanding of human disease and medical practice.² By 1905, many recognized that the old heroic treatments—purging, bleeding, cathartics, and proprietary medicines—were ineffective and dangerous. Simultaneously, new science-based practices of bacteriology, antiseptic surgery, and vaccinations were proving effective. The Flexner report codified the need to systematically integrate these scientific advances into the training of physicians.² Indeed, 2 of its enduring triumphs are the requirement for scientific training as a medical school admission criterion and the emphasis on basic science in the first 2 years of medical school.⁴

Today, the fundamental components of medicine go beyond the biomedical sciences to include its humanistic, legal, and management aspects. While science is absolutely essential, especially with greater precision in determining disease etiology through genetics and environmental influences, the limitations in practice increasingly result from systematic problems of implementation. Many of the medical services being delivered are irrelevant or harmful^{10 - 11} ; much of what has been proven effective is not being routinely delivered to patients.^{12 - 14} Consequently, hundreds of thousands are suffering and even dying prematurely while billions of dollars are wasted.¹⁵ These problems are not the result of a few “bad apples,” but of systematic failures to deliver proven interventions to patients.^{6 - 7 ,12} To apply 21st-century scientific advances effectively in the care of patients requires more emphasis on the humanistic, legal, and management sciences.

Flexner recognized that to improve medical care, highly prepared students had to be recruited to medical school largely by more rigorous science-focused premedical requirements; irrelevant material had to be eliminated and relevant basic science material required in the medical school curriculum.^{1 - 2} So too today.³ Because medical schools shape the subsequent learning of physicians, the focus should be on premed requirements and the medical school curriculum rather than graduate medical education.³ Changes at these stages are more tractable than reforming graduate medical education in which associations, specialty societies, specialty boards, accrediting bodies, and licensing authorities share responsibility but have no incentive to cooperate or coordinate their requirements, ensuring gridlock.⁴

What specific changes might be helpful?

By issuing admission requirements, medical schools have a profound impact on what thousands of college students learn and do not learn each year.³ Many premed requirements are irrelevant to future medical education and practice.^{3 ,16} Does knowing how to integrate sin θ have anything to do with caring for a patient or elucidating the role of TERC in aplastic anemia? Do any physicians, even researchers, have to know about Diels-Alder adducts? Is calculating the angular momentum of a spinning top relevant to any medical practice? Most of what is contained in 1 year of college calculus, organic chemistry, and physics is irrelevant to medical practitioners, researchers, and administrators. Researchers who need such information do not rely on their college courses.

Why are calculus, organic chemistry, and physics still premed requirements? Mainly to “weed out” students. Surely, it would be better to require challenging courses on topics germane to medical practice, research, or administration to assess the quality of prospective medical students, rather than irrelevant material.³

At least 6 relevant topics are not premed requirements. First, the mathematics most medical students need are statistics. Statistics are essential to reading the medical literature, designing research studies, and implementing quality improvement initiatives. Moreover, knowledge of statistics is more valuable for life and for being a thoughtful, informed citizen.

Genetics, molecular biology, and biochemistry are much more essential to medicine than organic chemistry and physics. True, some knowledge of nomenclature and organic structures and reactions is important for biochemistry, but the necessary material could be taught in a few weeks, rather than requiring an entire year of irrelevant synthetic pathways. Two courses encompassing genetics and molecular biology would be much more educationally valuable for medical students than one in physics.

As the mere existence of the Hippocratic oath attests, ethical challenges are inherent in medical practice and research.¹⁷ Yet there is no premed ethics requirement. Students need the ability to distinguish ethical issues from communications, economic issues, or aesthetic issues, to make ethical arguments, and to give ethical reasons that justify their decisions. Requiring a general ethics course is preferable to a focused bioethics course, which should wait until students have experience with actual patients and clinical dilemmas.

Moreover, much of the practice of medicine, as well as dealing with a research team and administering organizations, entails dealing with people and, therefore, human psychology. Requiring that students take a psychology course that provides education about established notions of human behavior, such as the fundamental attribution error, hindsight bias, transference, and moral distancing, could enhance physicians' interactions with patients, colleagues, and employees, not to mention their own families.

Discontinuing the requirements for calculus, organic chemistry, and physics would open up 6 semesters for more relevant courses. Adding 1 semester each of statistics, ethics, psychology, genetics, and molecular biology and 1 year of biochemistry, would require 1 semester less of course work if genetics and molecular biology satisfied the biology requirement. With this extra time, students could pursue other interests in this formative period, ensuring they received a true liberal education.

At the end of their careers, physicians tend to wax poetic about the art of medicine and how it is being lost. (The same art seems to be lost every generation.) As the 1984 report on the General Professional Education of the Physician and College Preparation for Medicine declared, much of what is included in medical school curricula is irrelevant to the actual day-to-day work of clinicians, researchers, and medical administrators, while much of what is excluded is very relevant.^{3 ,8}

Determining what courses are included and excluded from the curriculum is subject to fierce faculty battles. Each professor has a list of what could safely be eliminated, which is usually someone else's offering. Personally, despite being taught the Krebs cycle (twice during medical school as well as twice in college), I have never used it in my practice or research.⁸ My drug prescribing habits tended to be influenced by the handbooks I carried around rather than my pharmacology course. A lot of the pathology and cytology courses had virtually no impact either. It is doubtless that others will have different views about what is irrelevant.

Rather than debate what to reduce or eliminate, it might be more valuable to focus on what should be required as part of medical education: communication, bioethics, statistics, health care financing, health law, and management sciences.

Recognizing that communication and bioethics are necessary skills for providing effective medical practice, research, and administration, the Liaison Committee on Medical Education (LCME) requires “specific instruction in communication skills as they relate to physician responsibilities . . . [and] medical ethics and human values.”¹⁸ However, within the LCME's broad requirements, serious problems exist. The medical ethics requirement focuses on the ethical breaches in physician-patient relationships, marginalizing if not ignoring ethical issues related to scarce resources, public health emergencies, and basic and clinical research. In addition, for both ethics and communications “there is tremendous variation in the way, and extent to which [these] skills are taught and assessed.”¹⁹ These courses are frequently taught by faculty who lack formal training and are neither experts nor researchers in the area. These topics are often taught without an explicit conceptual framework to guide learning.^{19 - 20} Moreover, they tend to be taught once rather than continuously through medical training.

Hence, the challenge is to ensure that communications and bioethics education is more systematic and thoughtful.²⁰ In the first year, expert faculty should provide a formal introduction with a guiding framework. During clinical rotations, there should be repeated explicit instruction about practical applications of this framework as ethical issues arise and good communications can be modeled. In addition, in the fourth year a course should explicitly consolidate students' bioethics and communications learning. The “summing up” bioethics course could combine discussions about actual cases students have experienced in their clerkships with relevant readings; using standardized patients, good communication skills could be reinforced.

Of greater importance are areas that lack explicit LCME requirements, or are amalgamated into more vague requirements and may not be formally taught at all. While having statistics as a premed requirement will ensure that entering medical students grasp the basics, a formal statistics course in the first year would reinforce and apply the knowledge to reading the medical literature, analyzing research data, understanding health services research, and improving quality. Some schools teach statistics but most do not.

Health care now consumes more than $2 trillion per year. Health care is more than knowing what to provide. Reimbursement policies often determine what services are provided, and to whom. Practitioners and physician executives must understand how the financing system is structured, what services are covered by private insurance, Medicare, Medicaid, and other payers, and the incentives for clinicians implicit in reimbursement systems. It seems amazing to graduate physicians who have no idea what Medicare Part B is, the data on how copayments affect the use of medical services, how the resource-based relative value scale is determined and affects reimbursement, and why an aspirin administered in the hospital costs $20.

Whether addressing terminating artificial nutrition and hydration, reporting communicable diseases, obtaining informed consent, or battling malpractice suits, the law and court rulings substantially influence practices.²¹ That a student can graduate from medical school and not understand relevant health laws and how lawmakers and lawyers think about health care issues seems problematic.

Since 1905, the organization of the health care system has become much more complex. To deliver effective care or administer a practice, department, research laboratory, or hospital, physicians need to possess basic management skills. They frequently negotiate with patients about treatments and disease surveillance, and may also negotiate with colleagues and administrators about space and resources. Of necessity, physicians are participants as well as leaders of clinical, research, or administrative teams; they can participate in and lead teams better or worse.¹³ Whether administering a practice, a laboratory, a department, or a hospital, physicians need to know how to account for resources. They need to know how to assess performance and quality, and how to change organizations to improve the delivery of care. It is not sufficient to have a handful of medical students who will become investment bankers, corporate executives, or hospital administrators who earn masters of business administration degrees. Every physician needs to know the essentials of management sciences, including negotiations, leadership, personnel management, accounting, strategic planning, and performance assessment. These can no longer be considered incidental skills, but are integral to optimal functioning of clinicians, researchers, and administrators; and each of them can be taught.

These proposed additional courses for medical school are meant to be a necessary minimum of changes. They are not a substitute for the traditional training in pathophysiology, anatomy, and clinical rotations. These suggestions are not intended to be comprehensive; other courses, such as informatics, should also be required. These suggestions focus on curricular content, not addressing new teaching and learning methods.

Since each medical school organizes its curriculum differently, there can be no uniform approach to integrating these additional courses. However, certain scheduling possibilities seem reasonable.

The time saved in the first year of medical school by shifting genetics, molecular biology, and biochemistry to premed requirements might be used for expanded formal training in communication, bioethics, and statistics.

Conversely, health care financing, health law, and management courses as well as the consolidation courses for communications and bioethics can wait until the fourth year of medical school. Instead of a year dominated by “auditioning” subspeciality rotations, 3 rotations could be devoted to management and health care financing courses as 1- to 2-week executive-style trainings. This might offer an opportunity to initiate or further collaboration between medical and business schools. In addition, 1-week blocks should also be used for formal courses reinforcing the communication and bioethics lessons learned in the clinics. By bringing together fourth-year students dispersed through the clinical rotations, these sessions could enhance class coherence and facilitate the informal curriculum.

Similarly, a health law class for medical students might be taught with law and medical students together as a class in the fourth year. This would foster multidisciplinary learning. Such an experiment was successfully tried in the early 1990s at Harvard Medical and Law Schools.

The history of unrealized calls for medical education reform compels skepticism and the question: what leverage points might catalyze reform? Fortunately, unlike graduate medical education, the premed requirements and medical school curricula are not subject to control by myriad organizations with divergent interests. Regarding premed requirements, there are 2 keys: admission requirements and the Medical College Admission Test. For reform to be effective, most or all medical schools must change their admission requirements simultaneously. Otherwise, students applying to many schools would still have to satisfy both admissions criteria, increasing their course requirements. The Association of American Medical Colleges could facilitate this change. It also has authority over the Medical College Admission Test. By eliminating physics, organic chemistry, and calculus from the test, while incorporating genetics, molecular biology, biochemistry, and statistics, the education of premed students would change. Because these changes in premed requirements do not entail substantial medical school curricular reforms, they become comparatively easy for medical school deans. Thus, deans individually and collectively through the Association of American Medical Colleges occupy the strategic position for instituting changes in premed requirements.

The proposed changes in the medical school curriculum are the domain of the LCME, the accrediting authority for medical schools. By formally requiring statistics, health law, financing, and management courses and explicitly specifying the content that would fulfill the communications and bioethics requirements, the LCME can substantially shape medical school curricula. LCME is jointly governed by the Association of American Medical Colleges and the American Medical Association. These 2 organizations can improve the education of medical students by how they specify and enforce requirements.

Nearly 100 years after the Flexner report, the major challenge facing 21st century medicine is effective translation of medical science into practice and delivery. Just as Flexner recognized 100 years ago, achieving change today in medical practice requires a comprehensive change in premed requirements and medical school courses. It is time to eliminate irrelevant material and include relevant material, such as statistics and management sciences, currently excluded from medical student training. Only by this change can there be dramatic improvements in physicians' interaction with patients as well as the structure of the delivery system to ensure that patients receive known effective interventions.