Peer Review

Preparing for the New MCAT: The Perspective of Advisors

The last time the Medical College Admission Test (MCAT) was substantively revised was in 1991—ancient history to today’s premed students, most of whom had not yet been born. The same is true for premed advisors, most of whom had not yet been hired. Changing the MCAT, long a bedrock of premed advising, has been tantamount to causing an earthquake that is altering a landscape we thought we knew. The new version of the MCAT, dubbed MCAT2015, is barely on the horizon for current premed students but has already generated much angst among premed advisors.

The current MCAT consists of four sections—physical sciences, biological sciences, verbal reasoning, and a writing sample—that test knowledge of the basic sciences via questions drawn from traditional content areas such as biology, chemistry, and physics. The new MCAT also has four sections, but its sections test interdisciplinary concepts: Biological and Biochemical Foundations of Living Systems; Chemical and Physical Foundations of Biological Systems; Psychological, Social, and Biological Foundations of Behavior; and Critical Analysis and Reasoning Skills. Questions on MCAT2015 are drawn from the intersection between knowledge and skills: to find answers, students must use both their knowledge of the sciences and their scientific inquiry and reasoning skills. To increase score validity, sections of the MCAT2015 will include more questions, lengthening the test from its current 4 hours and 20 minutes to 6 hours and 15 minutes; including breaks and lunch, total time will be about 7.5 hours.

Advisors worry about the impact of a longer test day, possible increased costs, whether their students will be prepared, and about the timeframe for implementing a version for which details are yet to be worked out. Students who will take MCAT2015 are already in college and taking premed courses. Advisors also wonder whether their students will be taught the requisite knowledge and skills in the courses their institutions offer; because MCAT2015 tests interdisciplinary concepts, there is no established list of preparatory courses. In short, MCAT2015 appears innovative, even revolutionary, but many advisors are unsure how to advise their students.

The MCAT—Past, Present, and Future

In transitioning to the new exam, it helps to understand how the MCAT came to be and why it is now changing. Conventional wisdom points to Abraham Flexner’s Medical Education in the United States and Canada from 1910 as the starting point for academic expectations, standardization, and selectivity. Prior to Flexner’s report, there was little to no expectation of an academic foundation for admission to medical school. The report was scathing in its criticism of American medical education and resulted in the closing of many schools, significant changes in curricula, and the development of entrance requirements, including a standardized entrance exam in 1928, which eventually became the MCAT. By the 1940s, entrance requirements had significantly reduced the attrition rate of medical students from an all-time high of 50 percent in the 1920s to 7 percent by 1946.

Since its inception, the MCAT has been more dynamic than students and advisors have realized: it has undergone four comprehensive revisions, along with numerous minor changes, including developing new scoring systems, adding or eliminating content, reducing cultural bias, and in 2007, computer-based testing. MCAT2015 is the current, fifth revision. Not surprisingly for such a high-stakes exam, both major and minor revisions have typically been received with considerable anxiety. It is difficult to discern whether that anxiety arises more from the exam’s predictive validity, its lack of validity, or how its scores are used in admissions.

Over the decades, the MCAT has done well in predicting performance in Step I of the Medical Licensing Exam. Despite numerous studies, however, the data are less conclusive about predicting performance in the clinical years and in becoming “a good doctor.” Educators have long believed that there is more to becoming a successful physician than the ability to do science well, and both educators and admissions committees have sought ways to measure those elusive qualities, often called noncognitive variables. The importance of qualities such as cultural competence, understanding the social determinants of health, and appreciation of broader issues such as ethics are affirmed constantly even as debates continue over how to measure them, but the lure of metrics when evaluating vast numbers of applicants remain. Premed advisors have been keenly aware of mismatches between exceptional students and exceptional MCAT scores.

Recently, the Association of American Medical Colleges (AAMC) has launched numerous initiatives to explore solutions to this dilemma. In 1998, the Medical School Objectives Project identified the skills, attitudes, and knowledge that all graduating medical students should have. Educators have also been concerned about the information explosion and the increasingly rapid rate at which new knowledge is revising science. In response, the AAMC and the Howard Hughes Medical Institute identified what graduating physicians need to know about the natural sciences.

Their 2009 report, Scientific Foundations for Future Physicians, recommended a paradigm shift from fulfilling course requirements to building subject competencies on the theory that it will allow students with diverse educational backgrounds the greatest flexibility in preparing and demonstrating their suitability for a career in medicine.

And in 2011, Behavioral and Social Science Foundations for Future Physicians recommended incorporating behavioral and social sciences. With these three reports as backdrop, the Fifth MCAT Review (MR5) committee began its work. The result is MCAT2015, a competencies-based exam that tests both knowledge and skills in the natural and social sciences.

In some respects, we have come full circle, in that one of the most radical changes of MCAT2015, the inclusion of social sciences, has precedents in the MCATs administered between 1946 and 1977. From the beginning, there were complaints that those sections were culturally biased and that admissions committees paid them only lip service, according greater emphasis to natural science scores. For over thirty years, MCATs have focused on the natural sciences; it will be interesting to see how admissions committees use the four scores from MCAT2015.

What is abundantly clear is that changes in the MCAT are part of a ground swell transforming the educational landscape: technology and the information explosion; new educational theories; student learning outcomes and competencies instead of coursework. MCAT2015 is just one initiative among many to improve how medical schools evaluate, select, and educate tomorrow’s physicians: systems- and problem-based learning curricula; holistic admissions processes; and new evaluation tools such as the Personal Potential Index (PPI), Multiple Mini-Interviews (MMIs), and clinical scenario-based interviews. The MCAT is only one tool in a complex selection process that includes academic records, service, life experience, ethics, interpersonal skills, and professionalism.

The most pressing concerns for advisors revolve around identifying which courses will cover the material necessary to achieve the competencies. While competencies-based curricula are being developed, and may become commonplace at well-resourced institutions, they are not now in place at most schools. Advisors have been put in the position of advising students on MCAT2015 competencies with no clear-cut guidance on how or even whether medical schools will evaluate those competencies for admission purposes beyond performance on the MCAT. The advising community and undergraduate institutions recognize that competencies are powerful principles in guiding admission criteria, but the heart of education at undergraduate institutions is courses. Undergraduate courses provide students the opportunity to acquire the knowledge and skills that lead to competencies, and students’ performance in those courses can measure, at least to some extent, whether competencies have been acquired.

Premed Courses Not Yet Revised

While a specific list of premed courses, agreed upon by medical schools, would ensure consistency in advising, that appears unlikely. Most medical schools have not, or at least not yet, revised their prerequisite courses in light of MCAT2015, leaving students in the unenviable position of having to fulfill both prerequisites for medical schools as well as competencies for the MCAT. There should be substantial overlap between the two, but course content varies considerably between different institutions, especially in the social sciences.

To be fair, the idea that courses taken for the current MCAT cover everything tested is pure assumption. Having a list of courses has lulled institutions, advisors, and students into complacency; if students do not perform well on the MCAT, it must be the fault of students, not courses. Moving to competencies for MCAT2015 has exposed that assumption, making institutions and faculty uncomfortable. That courses vary from institution to institution is hardly news, but requiring competencies has shifted the responsibility for addressing discrepancies in the material covered from the AAMC, test-makers, and medical schools to individual institutions. The AAMC has made clear what knowledge and skills medical schools want applicants to have, and now each institution must decide what its courses do and do not cover. The looming question is who is, and who ought to be, making that decision. Some institutions have administrators and faculty engaged in determining answers; others have left the decision to their advisors, many of whom have no way of knowing which topics are covered. The MCAT2015 competencies can help institutions determine whether their courses are teaching what will be tested, but whether faculty will adjust their courses is quite another matter. As one professor snapped, “It’s not my job to teach for the MCAT.”

Mapping Courses to the MCAT2015 Competencies

However the decision is made, time is running out. Changes and information are still rolling out, and advisors have little time to communicate them, adjust their advising materials, and work with their faculty to map courses to the MCAT2015 competencies. Some advisors have requested that the AAMC delay implementation but acknowledge that the AAMC has already spent years on this initiative and that no length of delay will be adequate to ensure everyone is ready.

Premed advisors are also concerned about how the move to competencies will impact non-traditional and disadvantaged populations. Will less privileged populations have the social, experiential, and financial resources to navigate less clearly defined ways of preparing and to acquire competencies that require more than just coursework? Will preparing for MCAT2015 require the guidance of a dedicated, trained premed advisor, expertise that is unavailable at many institutions?

Some advisors have pointed out that although medical schools emphasize that they value all majors, additional requirements limit options. Non-science majors already have difficulty meeting current requirements; with the new set of requirements estimated conservatively at over 40 semester credits, the choice of majors that can be completed within four years will assuredly decrease. Advisors are also worried that requiring psychology and sociology will displace other health-related electives such as human development, nutrition, the ethics of health care, topics in public health, etc., further constraining the diverse paths students take in preparing for a career in medicine. Reducing the goal of understanding psychological, emotional, and sociological aspects down to a couple of introductory courses in sociology and psychology seems counterproductive. At many undergraduate institutions, there are a variety of behavioral science classes that do not require introductory psychology or sociology as prerequisites, and students are often able to take pertinent higher-level courses as electives.

There is widespread concern in the advising community that additional coursework may make it increasingly difficult for premed students to graduate in four years. There is an underlying fear that MCAT2015 will prove to be simply “more”: more courses, more credits, more extracurricular activities, and more time to graduation, at a time when institutions are focused on graduating students within four years. As yet, no one knows how many of which courses will be needed for MCAT2015; institutions and advisors have been hesitant to commit to a specified list while exam details are still changing. The more cynical advisors have wondered whether reconfiguring requirements into competencies is a way to increase requirements without the AAMC having to be the one to announce a longer list of required courses.

Finally, advisors are concerned that MCAT2015 will become even higher stakes than it already is. With the current MCAT, a weaker MCAT score can sometimes be offset by strong grades in the subject areas the MCAT purports to test, and vice versa. With MCAT2015, grades and scores may not serve as a cross-check, and a weaker MCAT2015 score may imply incompetence, whatever the student’s grades. In short, the fear is that MCAT2015 will be perceived as even more critical for the already highly competitive and hyper-achieving premed population.

The MCAT and the National Association of Advisors for the Health Professions

Throughout the process of developing and transitioning to a new MCAT, the AAMC has been responsive to advisors’ concerns, and the feedback loop between the AAMC and the National Association of Advisors for the Health Professions (NAAHP) has improved the process for all concerned.

Institutions are responding to the MCAT2015 in a variety of ways, ranging from rethinking curricula and creating premed tracks to no response, or at least waiting until someone takes the lead by publishing a list of recommended courses. Some institutions are piloting interdisciplinary programs that will allow premed students to obtain MCAT2015 competencies as part of their major; others are exploring ways to incorporate biochemistry into existing premed courses. The institutions of greatest concern are those without a dedicated, trained premed advisor to coordinate the response and manage the information flow, and the many community colleges, which are often staffed by generalist advisors and may not see a need to respond, since their students take the MCAT2015 after transferring out. Institutions that receive large numbers of transfer and community college students will need to work with their feeder schools to avoid an increase in their students’ time-to-graduation. Institutions that have premed advisors and large populations of premed students are responding proactively, using MCAT2015 as a catalyst to discussion and to updating curricula, as shown in the following reports, written by health advisors at the given institution.

Tufts University
The advisors at Tufts have been following the new MCAT with interest. This past summer, we met with our science chairs and premed committee. Introductory courses at Tufts already delve deeply into material, cover most of the competencies, and have high expectations for critical thinking, and we feel our students will be well prepared for the new exam. Our challenge is to meet the needs of premed students while maintaining the integrity of our courses and serving the needs of our other science majors. Faculty in the physical sciences are considering incorporating more examples from the life sciences as a way to make the subjects more relevant to premeds. The chemistry faculty are hoping to modify their usual course sequence from two semesters of inorganic plus two semesters of organic chemistry to two semesters of inorganic chemistry, incorporating some organic chemistry, plus one semester of organic chemistry followed by one semester of biochemistry. Chemistry majors will take an additional organic chemistry course covering synthesis, and biochemistry majors will take additional biochemistry courses; these latter courses for physical science majors will likely be much smaller, affording a more intimate, engaging experience. For the social sciences section, we do not want automatically to require introductory psychology and sociology. Many courses at Tufts address the social determinants of health, cultural competence, and more; this coming year, we hope to suggest a list of courses with additional preparation materials.

Colgate University
We have been proactive in providing information to faculty and students, including periodic updates to relevant departments and the Dean of Faculty. We have also engaged in ongoing dialogue with our Health Sciences Committee about the implications for advising students on how best to prepare for the upcoming changes to the MCAT. MCAT2015 has been a regular topic of conversation, particularly with the classes of 2015 and 2016. We strive to identify resources that will help our students not just prepare for the MCAT, but for their careers as physicians. Our premed students are advised to take at least one course in biochemistry, and our chemistry department recently began offering the foundational biochemistry course every semester, along with additional biochemistry options. Premed students can gain competency in statistics through a variety of departments, including mathematics (introductory and upper-division), biology, and psychology (both as part of the major requirements). Our premed students have long been advised to take courses in the behavioral and social sciences, many of which will also fulfill distribution and core requirements. We are in the process of mapping the foundational concepts of MCAT2015 to our courses, and our faculty will look to their professional organizations for guidance about possible changes in curricula.

Auburn University
At Auburn University, we formed an MCAT Committee that included both the former and new associate deans for Academic Affairs, the director of Pre-Health Programs, as well as faculty from the biology, chemistry, and physics departments. We also included both students who have done well on the MCAT and students who have not. Our committee was charged with identifying ways to help students prepare for the 2013 changes in the current MCAT—the omission of the writing section and the inclusion of experimental questions for MCAT2015—and for the new MCAT in 2015. We began by conducting a detailed review of current test content and then discussed the proposed changes for MCAT2015. We compiled a list of suggestions and appointed subcommittees to discuss ways to modify student attitudes and behavior when preparing for the MCAT; to supplement or modify our courses in order to add online MCAT content; to identify best practices for test preparation; and to consider changing our current advice about when to take the MCAT. Our MCAT committee met in mid-October to review suggestions and formulate an action plan.

University of Hawaii at Manoa (UHM)
At UHM, the Vice Chancellor for Academic Affairs convened our MCAT2015 Committee and appointed as chair the associate dean for medical education at our medical school. Our committee included the medical school’s director of admissions, the deans of the Colleges of Natural and Social Sciences, faculty chairs from biochemistry, biology, chemistry, mathematics, physics, psychology and sociology, and the Director of UHM’s Pre-Health/Pre-Law Advising Center (PAC). Our VCAA charged the committee with identifying which courses our premed students will need to prepare for MCAT2015 and with evaluating whether to formalize our premed track. Over the summer, we conducted a survey mapping UHM’s courses to the MCAT2015 competencies. Completed by teaching faculty and then corroborated and adjusted by students who have taken the courses, the survey yielded a list of recommended premed courses. The survey also indicated that covering all of the competencies would require significantly more courses than currently required. Responses from social sciences faculty included an unsettling number of “maybes,” depending on who taught the courses, and it was not at all clear that standardizing course content would be in best interests of our students or of the departments’ majors. We are still finalizing the results of the survey and are hoping to issue a list of recommended premed courses, as well as electives that go beyond MCAT competencies. Once that is in place, we will focus on re-examining our premed track.

Conclusion

Despite their many concerns about MCAT2015, most advisors welcome broadening the premed curriculum, in hopes it will better prepare students for careers as physicians. As we move toward implementation, there has been an outpouring of resources, creativity, and generally cooperative spirit among members of the advising and medical school communities. The AAMC has provided myriad resources—publications, including the essential Preview Guide; webcasts; and websites—to help students prepare and to help advisors and faculty determine how the competencies can be met through courses. The NAAHP has partnered with the AAMC to disseminate those resources online and through regional and national conferences. In general, the process has been admirably transparent and has initiated much-needed dialogue at institutions across the country, dialogues that are yielding innovative curricula.

Many premed advisors and students are still unaware of the coming changes, and many who are aware are anxious over the concerns raised. That “things will be different” for all concerned is certain, but exactly how is less clear; the AAMC and advisors frequently find themselves answering, “We don’t know yet.” One major unknown is how MCAT2015 will impact medical schools’ prerequisite courses. What we do know is that problems will shift, some fading, others persisting, and new ones appearing. For now, NAAHP advisors are focused on collaborating to resolve problems, facilitating the flow of information, and teaching their students how to navigate a changing world.

 

References

Association of American Medical Colleges. 2011. Preview Guide for MCAT2015. Washington, DC: Association of American Medical Colleges.

———. 2009. MR5: 5th Comprehensive Review of the MCAT Exam. Meeting handout. Accessed October 17, 2012, https://negea.uchc.edu/files/MR5AnnualMeetingHandout2009.pdf.

———. Behavioral and Social Science Foundations for Future Physicians. Accessed October 17, 2012, https://www.aamc.org/download/271020/data/behavioralandsocialsciencefoundationsforfuturephysicians.pdf.

———. MSOP: The Medical School Objectives Project. Accessed October 17, 2012, https://www.aamc.org/initiatives/msop/.

Association of American Medical Colleges and Howard Hughes Medical Institute. 2009. Scientific Foundations for Future Physicians. Accessed October 17, 2012, http://www.hhmi.org/grants/pdf/08-209_AAMC-HHMI_report.pdf.

McGaghie, W. C. 2002. “Assessing Readiness for Medical Education.” Journal of the American Medical Association 288 (9): 1085–1090.


Ruth O. Bingham is the president-elect of the National Association of Advisors for the Health Professions and director of the Pre-Health/Pre-Law Advising Center at the University of Hawaii at Manoa; Julie Chanatry is the president of the National Association of Advisors for the Health Professions and Chair of the Health Sciences Advisory Committee at Colgate University; Carol Baffi-Dugan is the chair of communications for the National Association of Advisors for the Health Professions, and associate dean of undergraduate education, director for Health Professions Advising at Tufts University; Beverley Childress is a member of the National Association of Advisors for the Health Professions, and director of Pre-Health Programs in College of Sciences and Mathematics at Auburn University; Susan A. Maxwell is the executive director of the National Association of Advisors for the Health Professions.

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