Peer Review

Faculty Leadership in Premedical Education

The new emphases in the MCAT exam will have ripple effects on curriculum, pedagogy, and student success. To ensure the effects are positive, faculty who work with undergraduates will want to reflect not only on how best to adapt courses, but also on how to advise students on entrance to medical school. Perhaps the biggest challenge will be how to ensure that a diverse population of students will discover and strengthen their aspirations for a medical career, and not fear that one standardized exam will be a barrier.

For some time, recognizing the specific challenges faced by minority and first-generation students, precollegiate programs such as Project Success at Boston’s West Roxbury High School and health science magnet schools in Dallas and Santa Monica have been identifying students who have the interest and potential for a medical career. Too often, without role models and appropriate counseling, these secondary school students do not take the mathematics and science courses that will be important for later success in college premedical requirements. Yet course work alone is not enough to build the confidence and competencies necessary for the level of challenge these students will encounter in college and medical school. Consequently, many of these specialty schools and inner-city programs use engaging pedagogical approaches such as inquiry learning, project-based work, and group collaboration to show students that they can take risks, learn through trial and error, and master increasingly complex material.

Similar initiatives—complemented by faculty and peer mentoring, internship opportunities, and research collaboration—are underway at the college level, aimed primarily at increasing both the number and diversity of students majoring in science, mathematics, computer science, and engineering. Comprehensive services including counseling, tutoring, cocurricular experiences, and career planning provide essential support so that more students will persist and meet demanding standards. Extending this type of outreach and support to students who may not have considered medicine before entering college, as well as to those who are taking the premed courses but majoring in other fields such as anthropology, international relations, and government, could increase the diversity of applicants to medical school. Students’ success, both on the new MCAT and in medical school, depends on a well-developed capacity to integrate all aspects of their education and apply their knowledge and skills to new problems and in varied contexts. Designing opportunities for this integrative work requires faculty leadership.

Models for Preparing Students for theNew MCAT

The articles in this issue of Peer Review note several ways that curricula might change to prepare students for the new Social and Behavioral Science component of the MCAT, including (1) adding courses in sociology, psychology, and statistics to the current recommended course work; (2) changing the format of introductory courses in both the sciences and the social and behavioral sciences to be more interdisciplinary and problem based, and (3) creating courses specifically designed for premedical students, either in the major or to meet general education requirements. Using several of the criteria for success on the new MCAT—for example, critical thinking; interpreting data; analyzing issues using methods and concepts from several fields; and understanding the interaction of physical, psychological, and behavioral aspects of health—suggests that how something is taught is as important as what is taught. Any of these curricular structures can allow students to achieve the learning outcomes, if content, competencies, and experiences are aligned. Even then, each model may have a different effect in encouraging access and preparing students for medical school.

Option 1, mandatory requirements, is the easiest to implement and requires little change by the faculty or the institution, but leaves the responsibility for integrating the learning to the student. Consequently, this option does not ensure that a student at “Random University” will be as encouraged or well-prepared as a student at “Elite University,” who may have the benefit of smaller classes, better premed advising, and research opportunities. The drawback of merely adding requirements is that a given institution may choose not to modify courses to accommodate changes in premed and MCAT preparation in favor of preserving existing requirements for traditional biochemistry, psychology, and physics majors, for example, as these introductory courses serve students seeking entrance to doctoral degree programs and non-medical careers.

Option 2 emphasizes new curricular designs and pedagogies developed by faculty from different disciplines working intensively together to rethink the concepts and relationships of both traditional courses such as biology and newer fields such as neuroscience. Despite over a decade of leadership and support from organizations such as Project Kaleidoscope and the National Science Foundation, advances in integrative science education have been slow and not widespread. Thus, the new MCAT requirements may increase interest in reworking courses to emphasize interdisciplinary scientific reasoning yet not be sufficient to affect large numbers of students. Even with innovative curricular work, the impact on increasing underrepresented students’ preparation for medical school may still be limited unless recruitment and retention are a conscious intention of faculty.

Option 3 could include topics courses in “Health Economics” and “Medical Anthropology” for majors or general education courses, such as “Global Health,” in addition to the introductory courses in the sciences that typically meet general education requirements. This option does not require significant institutional change as the courses can fit into current curricular structures and need not be restricted to declared premed students. First-year seminars (FYS) are a natural home for these types of courses as they have limited enrollment and are often designed to be interdisciplinary and focus on relevant societal issues as well as foundation skills in writing and research. With inviting titles such as “From Atomic Bombs to Cancer Treatments” (UNC Chapel Hill) and “Outbreak! The Intersection of Plagues and Epidemics with Human Culture and History” (Wheaton College), individual faculty and students can come together around topics of mutual interest and explore how concepts and skills can be applied beyond the classroom. If advising is linked to the small enrollment seminar, faculty have an opportunity to identify other students who could be successful in premed courses with the right support.

Many campuses use service learning to increase students’ understanding of the community and diversity and provide context for career aspirations. For example, students in a FYS focusing on community health designed a research project on access to food and recreation facilities in a low-income neighborhood and then conducted a community survey. The next semester the data was given to majors in an upper-level political science course to analyze and prepare a policy report to the city council and health department. Both groups of students attended the public oral presentation and the ensuing discussion gave gravity and meaning to their work.

For the first-year students, the experience could have piqued the interest of some who had not previously considered a medical career as there was a low barrier to involvement in research on a real health problem. For the majors, whether premed or not, the project had value because it enabled them to complete a research project in one semester and required many of the competencies emphasized in the new MCAT, including evaluating research design and drawing inferences from data. The simplicity of this curricular option, two faculty taking initiative and working together to show students how to apply their knowledge and inquiry skills to practical problems, is appealing but would still require significant faculty leadership to scale it up and create enough courses to meet the needs of students across various majors. It may be that the premedical advisors, complemented by colleagues from other disciplines, are well positioned to provide such leadership for both curricular transformation and initiatives that reach out to students who do not immediately identify themselves as premed.

Reworking Pedagogy to Strengthen Integrative Learning

At the same time that faculty adapt the content of the curriculum to prepare students for the new MCAT, they will also need to rework their pedagogy to strengthen opportunities for students to develop the advanced intellectual capacities needed not just for the exam but also for medical school. Lecturing may once have been an efficient way to transfer information but it is not effective in helping students learn to use their knowledge and skills to create new knowledge, nor is it the format for learning favored by medical schools today. As faculty have learned more about how the brain works and how individuals synthesize their learning and transfer it to new experiences, many have changed classroom practices to embrace different learning styles, create more collaborative environments, encourage students to take different perspectives on issues, and demonstrate that mistakes are moments of learning. Faculty development programs are inspiring and guiding this shift from teaching to learning.

Structures and relationships that guide students to practice communication and quantitative skills in many courses, integrate concepts and methods across disciplines, and connect course and cocurricular experiences to the community and careers can help students be more intentional and meet the level of learning required by the new MCAT and medical school. Through national projects and institutes, AAC&U is making visible the varieties of this applied and integrative work on campuses and giving special attention to the evidence that demonstrates that threading skills, practical experience, reflection, and collaboration intentionally throughout the academic experience increases students’ intellectual, social, and personal capacities. The evidence that high-impact practices (HIPs)—such as group projects, internships, international experience, and undergraduate research—deepen learning for all students is persuasive. Of particular relevance, however, are studies showing that HIP experiences have the greatest benefit for minority students, as measured by grade point average and degree completion (Kuh 2008).

The Role of Integrative Learning in from College to Medical Practice

Clearly, entrance to and success in medical school is not guaranteed by a high score on the MCAT exam or an A in organic chemistry. Medical schools also seek students who are well-rounded, resilient, confident, and compassionate. Of particular importance is attracting students who will practice in underserved areas as well as those with cultural competence essential to serving the changing demography of the United States. Thus, there is increasing interest in admitting both students from underrepresented populations and majority culture students with the capacities to bring sensitivity and equity to medical care. The current work by faculty on many campuses to integrate service learning, community projects, and global perspectives into the curriculum provides essential opportunities for all students to develop their appreciation of others and become more comfortable with their own identity. Looking to the future, it is not unlikely that fluency in two or more languages will be a requirement for medical school.

Leaving aside concerns about whether a standardized test is the best predictor of success in medical school, the emphasis on integrative learning and outcomes as preparation for the MCAT reflects changing views on high-quality education and is consistent with the expected continuum of learning for medical practitioners. As colleges and universities make changes in premedical education, so too are medical schools changing their curricula to include more problem-based learning, earlier interaction with patients, and integration of community and global perspectives. Graduate medical education through internships and residency is primarily experiential, closely mentored, and competency based, with emphasis on interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement equal in importance to medical knowledge and patient care.

Once in medical practice, physicians are now expected to maintain their skills and knowledge base through continuing education courses that require not just completion but a demonstration of competencies. This formal work is complemented by a self-directed “performance in practice” element utilizing periodic chart review in comparison to adopted professional practice parameters, direct feedback from peers and patients without necessarily the cover of anonymity, and an overall review of one’s practice as the basis for creating a plan for ongoing improvement. Faculty who want to reach more premedical students might adapt some of these elements that focus on achieving competencies rather than using courses, credits, or time to degree as measures of learning. Finding innovative ways to promote and extend students’ intellectual and personal development, such as through mentoring and feedback, peer review of their work, self-assessment, and intentional academic planning focused on career goals would serve all students.

Reference

Kuh, George D. 2008. High-Impact Educational Practices: What They Are, Who Has Access to Them, and Why They Matter. Washington, DC: Association of American Colleges and Universities.


Ann S. Ferren is a senior fellow at AAC&U; Peter M. Ferren is an associate clinical professor at the University of California–San Francisco School of Medicine.

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