Friday, December 6, 2013

MCAT Hyperbole

The Medical Education issue of JAMA came out today with two articles discussing the new and improved Medical College Admission Test (MCAT).  I read both articles and they reminded me of the new and improved MCAT that I took back in the day when I applied to medical school.  I think that we were about two years into the new and improved version then.  I could not tell the difference between physicians selected on the basis of the old version, the new version or no versions of the MCAT.  I am sure that many of the professors that I identified with had never taken an MCAT.  Many were not trained in the United States.  Good doctors are good doctors and the idea that a multiple choice test will pick them seems about as likely as making accurate diagnoses of depression using a multiple choice questionnaire.

At the time I took the exam, there were all sorts of ideas about how you could select a "good" doctor.  They were in a trend where science was being deemphasized.  Somebody had the idea that you had to be "well rounded" with a liberal arts education.  Pure science majors might be frowned upon.  As a Biology/Chemistry major - did I stand a chance?  They had just phased out the General Knowledge section of the MCAT.  The rumor was it discriminated against students born and raised in rural areas with no access to museums, art, and theater.  As a Jack Pine Savage (I like the loose definition of a native from the natural range of Pinus banksiana) - I probably dodged a bullet there.  Critical thinking was emphasized.  It always is in these tests.  I took the GRE and they said the same thing.  It seemed like the critical phase of the admissions process was the interview.  I was interviewed by a Cardiologist who wanted to know if I was "aggressive" enough.  I did not know what he meant and stammered for quite a while.  Then he learned I was in the Peace Corps and said: "Anyone sitting in the bush for two years is aggressive enough for me."  He gave me a favorable rating.

The new MCAT promises to pick doctors of the future better.  It is described as being the product of a survey of 2700 shareholders.  It is supposed to be designed to test the competencies suggested in two reports - The Scientific Foundations for Future Physicians and Behavioral and Social Science Foundations for Future Physicians.  In the current JAMA article one of the authors defines 4 signals that the new MCAT sends for the future of medicine as summarized in the Table below (per reference 2):

Signals Sent by the MCAT Revision
Focus on foundational competencies required of future physicians rather than specific undergrad courses.
Candidates must be able to learn and think like scientists.
Behavior interacts with biology.
Critical thinking will be emphasized with a balanced testing between natural sciences and social/behavioral sciences.

None of these ideas seems revolutionary to me.  Looking at the second signal:  "Candidates must be able to learn and think like scientists."  I can think of no better way to do that than take a senior level chemistry or physics course from an interesting professor.  For me it was Physical Chemistry, the dreaded course of Chem majors.  You either were or you were not a Chem major based on whether or not you passed PChem.  It was the most mentally strenuous course I have ever taken and there certainly were no medical school courses that came close.  I can still recall studying thermodynamics and learning how Maxwell and Gibbs thought about things.  Our professor even digressed to talk about how long it took Linus Pauling to learn thermodynamics.  I still have thermodynamics swirling in the background whenever I see crystals dissolving in a solution, whenever I have to bring my car battery in the house to warm it up, and whenever I am thinking about complicated pharmacodynamic interactions.  Keep in mind that at the time I took the MCAT, science majors were out of favor.  The thinking at the time was that you would develop critical thinking from a liberal arts education with only the core science course (general chemistry, organic chemistry, quantitative analysis, and physics) being specified.  Unless you are Gauss, I think that generally involves some level of advanced training beyond what are generally the rote courses.

What actually happened to the cohort of physicians trained under the previous iterations of MCAT?  I am thoroughly biased by my undergrad training and always like to hear about other undergrad chem majors.  In the department where I previously worked there were two and they are excellent psychiatrists.  There are chem majors in every medical and surgical speciality and they are excellent physicians even if they did not have the same amount of humanities courses.  At the same time I have encountered excellent physicians from practically every undergraduate major ranging from music performance to applied mathematics.  The only logical conclusion is that the undergraduate medical education system can turn any reasonably bright group of people into physicians irrespective of their undergraduate majors or MCAT results.  It seems to me that some of these documents emphasize the MCAT as the limiting factor when there is no evidence to suggest that is true.  How can it be considered a signal when the signals are the same ones that have been important since formal education of physicians began?

The real area where physicians are produced is in medical school and if you want physicians to think like scientists that is also the logical place where it happens.  Recalling my biochemistry course in medical school - there was practically no memorization.  We had a seminar group (in addition to lectures) where ten of us were expected to discuss state-of-the-art biochemistry experiments at the time and on an ongoing basis.  Volumes of these papers were assigned - each emphasizing a specific concept.  We had to know the experimental methods and the limitations.  We were also expected to have a subscription to the New England Journal of Medicine and discuss any relevant research there.  The exams were essays about these experiments and methods.  They were 7 points apiece and you had to get a 6 or a 7 on each exam to pass.  There was an undercurrent of dissatisfaction by many with the typical complaint being that we would go into the board exams at a disadvantage because we were not memorizing metabolic pathways. 

During the clinical years, the formative process was seeing and identifying with professors who were excellent clinicians and scholars.  They did not have to be scientists in the Kandel sense of the word, but they needed to be scholarly, well-read, and experts in their field.  For me the most engaging process was being on a team with one or two of these folks, senior residents and me as the medical student. That dynamic learning environment was absolutely the best way to acquire the skills, attitudes, and knowledge base requires to be a physician.

So where does that leave me with regard to the messages of the main article and the opinion piece?  I think the science aspect of the MCAT is overemphasized but not for the reason that Cohen suggests in the editorial.  I have always believed that physicians should think like scientists and we are ethically obliged to provide scientifically based treatment.  The problem is that physicians are currently practicing in an unscientific environment.  Any scientist would be appalled at the number of pseudoscientific guidelines and quality markers that physicians have to adhere to.  They range from the purely financially based to management decisions negating any critical analysis that a physician may come up with.  The wringing of science out of medicine is a direct result of the political theory that funding private businesses to ration health care is an effective way to reduce health care inflation and it certainly is not.  I don't think it is honest to build medicine up as an intellectual endeavor when physicians will be routinely second guessed by administrators who often have only business training.  We need to tell the people who are truly interested in science to go into science and engineering and avoid medicine.  And if that is really true why are we interested in physicians thinking like scientists at all?   

Cohen's editorial has two issues that I would like to comment on.  The first has to do with what he describes as "skills previous generations of physicians had scant use for" among them "how to use resources parsimoniously".  As a member of the medical specialty that has been viciously rationed over the past three decades to the point where there are marginal resources to treat the most ill patients, I say it is time to get rid of the "cost effectiveness" argument.  It has been the battle cry of the managed care industry and you only have to look as far as your nearest emergency department to see the result.  Pricing is the largest single economic problem in American medicine and the best way to address it is to get the prices on par with other efficient health care systems (like Japan) and to suggest that managed care companies owning the means of production (MRI scanners, cardiology clinics, hospitals, etc) is a massive conflict of interest resulting in prices that are much higher than they are anywhere else in the world.

The second issue is Cohen's multidisciplinary team concept.  His view is that physicians need to "demonstrate antihierarchical teamwork".  His ideal team of the future eschews individual accountability and ability to function as a leader but also as an equally valuable member.  Like most other areas of medicine, psychiatric expertise and experience in this area is ignored.  I had a multidisciplinary team that met on a daily basis for 23 years.  We met during a time when the dark forces within managed care were telling us we didn't need to meet and we met during a time when they wanted us to meet so that they could put case managers on the team and tell us what to do.  Apart from the expected negative influences of managed care, teams depend on a number of practical issues including the number of full time employees and who is present when patients are admitted, discharged, and when their family members show up.  In those 23 years there were no other team members present for the time that I was present and I viewed it as my job to communicate what happened to everyone else.  The other practical matter and a significant cost factor that Cohen may wish to compensate for by parsimonious use of resources is defensive medicine and all that entails.

In conclusion,  I don't have a favorable view of either of these articles for the previously stated reasons.  The  best way to assure that future physicians have what it takes is to make sure that they have a practice environment that is intellectually and professionally stimulating.  Can you really expect that medicine can continue to attract high quality candidates from all undergraduate majors if the practice environment remains stagnant or deteriorates further?  You can't expect to have people thinking like scientists when they are managed like production workers by people with no knowledge of medicine or science.  At the very best, you will end up with highly frustrated overtrained professionals or at the worst a much wider range of skills than currently exists in the field.  By that I mean the spread of applicant qualifications will increase and the brightest people will go to any school that can get them placed outside of the current managed care environment as the health care system evolves into two tiers of care.

When that day comes, the nature of and scores on the MCAT will be meaningless.

George Dawson, MD, DFAPA

1: Cohen JJ. Will changes in the MCAT and USMLE ensure that future physicians have what it takes? JAMA. 2013 Dec 4;310(21):2253-4. doi: 10.1001/jama.2013.283389. PubMed PMID: 24302085.

2: Kirch DG, Mitchell K, Ast C. The new 2015 MCAT: testing competencies. JAMA.  2013 Dec 4;310(21):2243-4. doi: 10.1001/jama.2013.282093. PubMed PMID: 24302080.


  1. Years ago, a friend of mine, a biochemist, was on the admissions committee of a NYC medical school, which will remain unnamed. They did an experiment. They took all the applications, put them in a pile, randomly pulled out 20%,and admitted those applicants. Then they followed them through medical school to see how they did, and there was no difference between the "randoms" and everyone else.
    Medicine is not science. That's an important point, which becomes obvious if you interact with real scientists. I decided to go to med school after a year in grad school studying math. I had to take some premed classes, like chem/orgo/bio, and coming from math, these were not challenging. But they were well taught, and the professors pushed the students to really think, not just memorize. Then I got to med school, and the thinking stopped.
    New and improved MCATs? Sounds like just another poorly thought out idea that will please some pencil pushers but accomplish nothing. Doctors need a wide body of medical knowledge, but we also need to think, and you learn that from doing it, not from preparing for a newfangled exam.

    1. "Sounds like just another poorly thought out idea that will please some pencil pushers but accomplish nothing. Doctors need a wide body of medical knowledge, but we also need to think, and you learn that from doing it, not from preparing for a newfangled exam"

      I am assuming that "pencil pushers" is fighting words for an analyst.

      I agree completely and would have woven the tapestry of similarity between these pencil pushers and those working on MOC and the Medicare quality markers I previously posted but felt I was going a little long for a blog post.

      I think the conflicts of interest are the same. Anytime you give somebody a job much less pay them well for oversight, they will come up with a plan - usually at some cost to those being overseen.