The American Journal of Medicine
Volume 122, Issue 2 , Pages 104-106, February 2009

Premed Requirements: The Time for Change Is Long Overdue!

University of Arizona College of Medicine, Tucson

Article Outline

 

Each fall, thousands of eager students head off to college with the dream that they will become physicians or other health care professionals. Unfortunately, the dream will come true only for a minority. What happens to the rest of the dreamers? They run afoul of the premed requirements, or if they manage to master the premed requirements, they may be rejected because not enough first-year positions are offered in US allopathic medical schools.1

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Where Did the Premed Requirements Come from? 

Before the 20th century, there were few formal requirements for admission to US medical schools.2

In 1904, the American Medical Association created a Council on Medical Education to promote the restructuring of US medical education and to standardize the preliminary requirements for entry into medical school.3 In 1908, the Council invited the Carnegie Foundation to conduct a survey of medical schools to promote reform. Abraham Flexner was chosen to lead the survey.

After surveying all the existing medical schools, Flexner4 issued his famous report in 1910. He reported that admission to medical school requires competent knowledge of chemistry, biology, botany, and physics.

By 1930, the minimum requirements for admission to medical school were clearly established: 60 hours (2 years) of college were required.5 More than half of the 60 hours were specified: 8 hours (2 semesters) each of general chemistry, physics, and biology; 1 semester of organic chemistry; and 6 hours of English composition were required.6 The only change in the last 78 years has been the addition of a math/calculus requirement, and the required organic chemistry has increased from 1 semester to 1 year. Nearly all of the health professions have adopted the same requirements.

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What Is the Purpose of the Premedical Curriculum? 

In 1926, Capen5 said that the premed curriculum was established to give students a broader and sounder education. In 1939, Furstenberg7 said that the purpose of premedical education is to give students a broad general education before beginning the study of medicine. Most recently, Kanter8 stated that the premed curriculum should provide a broad-based education that will prepare the student to develop into an independent and creative thinker.

Criticism of the premed requirements began soon after they were adopted and has continued to the present time. In 1926, Capen5 noted that the purpose of the premed curriculum was somewhat defeated when some of the basic sciences previously taught in medical school were transferred to the premed curriculum. In 1929, Shumway9 wrote that the time in the sciences should be decreased, allowing more time for electives. In 1939, Furstenberg7 reported that the premed curriculum deals with abstruse learning and has wandered from its original purpose.

In 1939, the Association of American Medical Colleges went on record to express its displeasure with the premed curriculum.10 They opposed the regimentation and the loss of choice of subjects. “There is a tendency to overemphasize the science content of premed to the neglect of the social sciences and the humanities.”10

Many others have reported that the heavy emphasis on the sciences presents an obstacle to the premed student's obtaining a broad education. We doubt that anyone would suggest that calculus, physics, and organic chemistry represent the essence of a broad-based education. In 1968, Page11 said that we need to take a hard look at the required sciences to determine what is necessary for the practice of medicine and eliminate material that may be a “baptism of fire.” In 1976, Gellhorn12 likened the required premed science courses to the hazing of pledges in fraternities. They both require difficult tasks that contribute little or nothing to the career aspirations of the student.

In 1980, Dickman and colleagues13 suggested that the necessity of the heavy concentration in the natural sciences should be reconsidered. In 1988, Alpert and Coles14 wrote that the majority of physicians do not need the intense instruction on biomedical science that they now receive.

The current president of the Association of American Medical Colleges has suggested that “our goal should be to provide students the greatest amount of flexibility, while ensuring they are prepared for early work in medical school.”15 The current premed curriculum will never be labeled flexible!

Kanter,8 the current editor of Academic Medicine, has suggested that we need to reexamine which courses should be required for entry to medical school and then revise the content of the Medical College Admission Test (MCAT).

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Are the Required Premed Courses Needed to Prepare for Medical School? 

The presumed reason for so many science courses was the belief that these courses are necessary to prepare students for the basic science courses in medical school.

There is no evidence that physics or calculus is needed to prepare for the basic sciences. Some believe that organic chemistry is important to understand biochemistry. However, it has been suggested that the relevant portions of organic chemistry could be incorporated into a biochemistry course.16, 17 Alpert and Coles16 note that success in organic chemistry depends on “unquestioning meticulous memorization.” These are certainly not the qualities that we look for in the competent physician.

The premed requirements have been under attack by medical educators for at least 80 years; yet they remain intact.

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Is the Purpose of the Premed Courses to Maximize Medical College Admission Test Scores? 

The required courses help students to maximize their scores on the MCAT, which bases many of its questions on materials contained in the required premed courses. Success on the MCAT is crucial to gain acceptance to medical school. However, if much of the material in the required courses is not relevant to the practice of medicine, one must question if success on the MCAT is predictive of future success as a physician.

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Is the Main Purpose of the Premed Courses to Limit the Number of Applicants? 

Many suggest that the main purpose of the required courses is to reduce the number of applicants for medical school.16, 18, 19, 20, 21 The course that most agree is key to “weeding out” applicants is organic chemistry.16, 18, 21, 22 Brieger22 noted that organic chemistry began to take shape as one of the defining premedical sciences in the 1920s. Many chemistry departments have the reputation of tough graders.22 Some premed advisors tell students who receive less than a “B” in organic chemistry to look for other careers.16

Barr and colleagues18 studied 362 freshmen premed students at Stanford from 2002 to 2007. When students who dropped premed were interviewed, 85% said that at least one course in their first 2 years discouraged them from medicine. The most frequent course? Organic chemistry! Success in organic chemistry is seen by many admissions committees to be essential to be admitted to medical school.

Lovecchio and Dundes21 also studied students who had dropped out of premed. Seventy-eight percent said that their grade in organic chemistry was the reason that they dropped premed. The authors stated: “It may be time to consider whether a single course (organic chemistry) should contribute to eliminating persons who might otherwise excel as physicians.” Is there any reason to believe that success in obtaining an “A” or “B” in organic chemistry is predictive of success as a physician?

If the real purpose of the premed requirements is to “to weed-out,”17, 18, 19, 21 “to separate the wheat from chaff,”20 or to serve as “a trial by fire,”12 “a sifting process,”20 or “a culling process,”21 there must be a better way to determine whose dreams of being a physician or other health professional will be realized.

Many would agree with Emanuel's19 assessment that calculus, organic chemistry, and physics are irrelevant to medical education and practice. Unless it can be established that these courses are essential to learn the basic science courses in medical school, they should not be required for entry to medical school. As always, we welcome comments via-email or our blog, http://amjmed.blogspot.com.

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References 

  1. Dalen JE. The moratorium on US medical school enrollment, from 1980 to 2005: what were we thinking?. Am J Med. 2008;121:e1–e2
  2. Fishbein RH. Origins of modern premedical education. Acad Med. 2001;76:435-429
  3. Beck AH. The Flexner report and the standardization of American medical education. JAMA. 2004;291:2139–2140
  4. Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910;
  5. Capen SP. Premedical education. Bull AAMC. 1926;1:4–9
  6. Clarke HT. Premedical requirements in chemistry. J AAMC. 1930;5:134–137
  7. Furstenberg AH. Anent “premedical” education. J AAMC. 1939;14:276–277
  8. Kanter SL. Toward a sound philosophy of premedical education. Acad Med. 2008;83:423–424
  9. Shumway W. Premedical education from the standpoint of the liberal arts college. J AAMC. 1929;4:111–115
  10. Zapffe FC. Premedical education. J AAMC. 1947;22:240–241
  11. Page RG. Impact of changes in premedical education on medical education. J Med Ed. 1968;43:717–723
  12. Gellhorn A. Premedical curriculum. J Med Ed. 1976;51:616–617
  13. Dickman RL, Sarnacki RE, Schimpfhauser FT, Katz LA. Medical students from natural science and nonscience undergraduate backgrounds (Similar academic performance and residency selection). JAMA. 1980;243:2506–2509
  14. Alpert JS, Coles R. The indigestible curriculum. Arch Intern Med. 1988;148:277–278
  15. Kirch DG. A word from the president: “the gateway to being a doctor: rethinking premedical education.”. AAMC Reporter; 2008;April
  16. Alpert JS, Coles R. Premedical education a modest proposal repeated. Arch Intern Med. 1987;147:633–634
  17. Dienstag JL. Relevance and rigor in premedical education. N Engl J Med. 2008;359:221–224
  18. Barr DA, Gonzalez ME, Wanat SF. The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students. Acad Med. 2008;83:503–511
  19. Emanuel EJ. Changing premed requirements and the medical curriculum. JAMA. 2006;296:1128–1131
  20. Gross JP, Mommaerts CD, Earl D, DeVries RG. After a century of criticizing premedical education, are we missing the point?. Acad Med. 2008;83:516–520
  21. Lovecchio K, Dundes L. Premed survival: understanding the culling process in premedical undergraduate education. Acad Med. 2002;77:719–724
  22. Brieger GH. The plight of premedical education: myths and misperceptions—part II: science “versus” the liberal arts. Acad Med. 1999;74:1217–1221

 Funding: None.

 Conflict of Interest: None of the authors have any conflicts of interest associated with the work presented in this article.

 Authorship: Both authors had access to the data and a role in writing the article.

PII: S0002-9343(08)00973-X

doi:10.1016/j.amjmed.2008.08.027

The American Journal of Medicine
Volume 122, Issue 2 , Pages 104-106, February 2009

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