Every year, medical school hopefuls sit down to endure a grinding six-hour hazing ritual known as the MCAT: the Medical College Admission Test. For the fourth time in its history, the committee that oversees the exam is considering a major overhaul of the exam.
So if you’re not in the line-up to apply for medical school, what interest could this possibly hold for you? The training of medical professionals plays an enormous – and understated role – in the functioning of the medical system that is helmed by people who have survived this training regimen. It starts before the MCAT, but this test is emblematic of some of the sustaining flaws that drive classical medical training, and some of the places where real reform might create sustainable change in the overall health care system.
The traditional MCAT covers the core sciences required of premed students: physics, chemistry, biology, a little biochemistry. It tests stamina as dearly as knowledge, and does well to predict “success” in medical school, as measured by the ability to pass subsequent tests and achieve reasonable scores of the various board exams required along the way. It is notoriously poor at predicting ethics, clinical performance, or personalities compatible with patient care, and this is part of the current drive for reform. Critics of reform argue that these traits are picked up in personal statements and interviews – the MCAT is a test of knowledge, dedication, and stamina that is necessary to weed out unprepared students without sufficient mental moxy for the program; pro-reform proponents advocate for inserting material coverage psychology or sociology, or adding personality inventories alongside the exam.
All of these, I argue, fundamentally miss the point. No one, I believe, thinks that medical education should be less rigorous. It is the content of medical education – from the MCAT on up – that needs a fundamental shift, and that idea is hardly even on the table.
As it stands today, medical students take four years of undergraduate courses (in any field, though including the core science courses), then complete two years of pre-clinical studies, two years of clinical rotations, and a minimum three-year residency. Of these minimum eleven years of study, you may be surprised to know that fully half (the undergraduate and pre-clinical years) are only tangentially related to what a medical student ends up doing with their life; the rest are an amalgam of requirements and hoops that largely defy any utility to the task of medicine. This starts with the MCAT and the requirements that drive it; it continues with the first step of US Medical Licensing Examination, which covers such gross detail of non-clinical topics that medical schools are forced to focus away from clinical medicine for the first two years if only to get students to pass this exam. School to school and administrator to administrator, medical colleges are themselves are not immune from promulgating the idea that every student should take a rapt interest in the minutiae of topics that certainly hold distant relevance to medicine, but simply cannot be memorized at that detail with massive expansion of knowledge the world is currently experiencing.
The worst offender of my pre-clinical years was a neuroscience course in which we memorized in agonizing minutiaea the microanatomy of every nerve course through the spinal cord at a level of detail that was beyond most practicing neurosurgeons; we glossed over salient issues like anti-depressants, biological bases of behavior, and neurological disease in 15 minute spurts. When negative feedback about the non-clinical focus of the course reached the director, he nonchalantly dismissed these concerns by telling us, “Don’t worry – you’ll learn that in your clinical years!” Indeed, it was accepted wisdom that two pre-clinical years of cramming information that would never be accessed again was a reasonable norm – that this was a good use of limited training time.
The sum effect of the diversion of time from learning about medicine to mastering an arcane level of detail more appropriate to research-guided PhDs is that the timeframe for learning clinical medicine is shoved into an accelerated five years for general medicine (or longer, for surgery or medical specialties). This feeds the pressure and rush of the residency years, as well as the back-pressure against resident work-hours reform – after all, there is a limited time in which to master this immense volume of clinical skill: six years have already been burned on other topics, so few are left for the meat of the career. This does not begin to address the investment expense required to throw six years of non-clinical training at every doctor – expense that is taken up by state funds and private debt alike, which in turn drives medical students away from critical but lower-paying careers like primary care. And in my experience, it is often the burn of the residency years that fundamentally shapes many physicians’ attitudes toward work, burnout, reimbursement, and debt. You cannot repay what young physicians endure during residency; most take it back the only way they can – monetarily.
True reform of the MCAT would mean a massive retrospective review of what pre-medical training and characteristics drive an acquisition of skill, an aptitude for the profession, and a likelihood of filling specialties we need most at this moment in time. True reform would also mean canning the entire content of the first step board exam in favor of material that is salient to the profession instead of cowing to the traditionalist ideal that every physician should have a classical education (which is promptly forgotten in favor of the vast chunk of knowledge that MDs are required to carry around in their heads day-to-day). No one is arguing for dropping the rigors of testing; but perhaps cutting the pre-med organic chemistry in favor of anatomy, or dropping the second semester of physics in favor of genetics, may actually produce more apt physicians who do not find themselves not behind the eight-ball of burnout so early in their career.
On its own the MCAT is certainly not a solo-flying herald or cause of inefficiency in the medical system. But it is the entry point into a system that emphasizes hell-bent tradition over efficiency or pragmatism at all points along the way – and it is no wonder that those who experience it come out the other end with a set of priorities that reflect the values of the training they endured.
Cross-posted from my recently re-located and re-launched blog, now found at America, Love It or Heal It.