"First do no harm": Medical School Admissions Requirements and Educational Malpractice
After trying to get this published in a number of high profile biology-centric journals and being turned out without review - I am ready to move on.
[this is meant to be a shorter and punchier version of “The toxic effects of medical school course requirements on inclusion and the understanding of biological systems” Children are often fascinated by living things. Recent experiences with my grandson
revealed the attractive nature of owls, bears, pillbugs, and dinosaurs, particularly Pachycephalosaurs and Tyrannosaurs. For some, this interest deepens over time into aspirations for a biology-based career. A simple Google search (↓)reveals the proliferation of such careers, from K-12 teachers and health care providers to jobs associated with the burgeoning biotechnology/pharmaceutical industries, and supporting domains including intellectual property, finance, regulation, marketing, education, and public policy, as well as the wide range of sociopolitical and legal issues associated with environmental change, drugs, and medical procedures. New and more powerful methods of genetic engineering, many based on CRISPR-Cas9, derived from a bacterial immune system accelerate career diversity in this arena. Such tools have ever-expanding applications in and implications for a range of medically and socially relevant areas, including embryonic engineering and the development of personalized, effective, and expensive medical treatments. There is a rapidly growing and detailed understanding of the molecular and cellular processes that underlie all known biological systems reflecting their apparent descent from a common ancestor (e.g. Weiss et al., 2018; Crappitto et al., 2022), a powerful line of evidence supporting evolutionary theory. At the same time, we are coming to understand how differences between species and between individuals arise from genomic (DNA-based) differences, environmental histories, and molecular level "noise," differences that can influence one's response to environmental insults, pathogens, drugs, and stress. While this is an area of active research, with much left to learn, it is clear that the explosion in our molecular level understanding of biological systems raises questions with widely ranging and serious personal and socio-economic implications.
How is the education establishment, particularly at the college and university level, addressing the explosion of biological knowledge and the ability to make sense of it? How well do individual courses and overall curricula help students master what they need to know and develop the mental tools to apply it in a justifiably confident and sensible way? All too often there is an implicit assumption, particularly in molecular biology degree programs, that the primary "goal" of a biology degree is to apply to medical or graduate school, rather than to develop an understanding of the basic properties and processes that underlie biological systems (e.g. Klymkowsky, 2010) and that can be put to use in the wide range of biology related careers (FIg.1). The result is that too often biology department faculty, specifically in the United States, adopt the course requirements laid out by the Association of American Medical Colleges (here for 2024) without regard to their relevance or efficacy, in terms of what students can be expected to learn as it relates to modern biology. These decisions impact all students, whether interested in medicine or not. Medical school admissions course requirements can result in biology students having to take as many or more credit hours in chemistry than their required biology courses, a situation that can crowd out opportunities to master skills and subject areas valuable for other career paths. The result is a situation analogous to medical malpractice. It is as if your primary care doctor (your biology degree program) sends you to a specialist for a disease you do not have (e.g., several semesters of organic chemistry and calculus), and fails to provide you with treatments you will need later on, in the form of courses and opportunities relevant to various career paths.
This situation raises two questions. The first is whether the courses required by medical school admissions committees are relevant, necessary, and effective in helping students master ideas important for the practice of medicine? Dalen & Alpert (2009) note that many pre-med course requirements serve as a "baptism of fire" involving "difficult tasks that contribute little or nothing to the career aspirations of the student," and that "many would agree with Emanuel’s (2008) 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." Students, and more concerningly instructors (and perhaps medical school admissions committees), often view these courses as serving a weed-out rather than an educational function (Weston et al., 2019, Tran 2022). Unfortunately, the overarching effect is to negatively impact a wide range of students who might gain from more coherent curricular design and may lack the "social capital" (Saw, 2020) to deal successfully with such unnecessary obstacles.
Biology department faculty need to answer a second question; what, exactly, do undergraduate biology students need to master and whether that answer differs from what pre-medical students need? Physical and chemical principles constrain biological systems, whose complexities arise from networks of molecular and cellular interactions, characterized by multilayered feedback systems (Cowan et al., 2014). Students need to understand these principles and how they are based on molecular level interactions, interactions that influence all aspects of biological systems. But noted by Banks and Vernon (1970) over fifty years ago “simple thermodynamic parameters are irrelevant in discussing whole organisms: these must be understood in kinetic and mechanistic terms. ... the exclusion of simple thermodynamic considerations enormously simplifies the discussion."“ Basically, the conventional approaches used in most chemistry courses often fail to help students understand the molecular processes involved in the formation, stability, and dissociation of molecular interactions. How best to introduce students to the underlying principles that shape biological systems? I would argue, it involves introducing students to chemical and physical concepts in the context of biological systems. If medical school admissions committees would articulate their desired learning outcomes, then the need to require specific courses would be eliminated, and biology departments could work to ensure students meet these learning outcomes. Sadly, it is rare that college administrators see as a priority student learning outcomes and the redesign efforts needed to improve them, a point made in a recent Wall Street Journal essay (see Belkin, 2024). Instead most institutions appear to be satisfied with superficial and readily manipulatable student surveys of instructor popularity (see Gutkin, 2023). It is therefore not surprising that there is rarely a compelling reason, or the resources necessary, for faculty to spend the time and effort needed to improve course and curricular design. Add to this the implicit presumption that the design, relevance, impact, and educational effectiveness of extra-departmental required courses are not the responsibility of the department that requires them, which serves to sweep the impact of these courses under the rug.
A common objection to the type of course and curricular redesign that I am proposing is that it will result in the dumbing down of degree programs. The evidence suggests the opposite. Experiences with a revised curriculum in chemistry (see Underwood et al., 2023) indicate that students come to better understand key aspects of chemistry (e.g., Matz et al., 2018). Rigorous comparative studies between rethought versus conventional courses are extremely rare and require resources and motivation to happen. As Harris et al (2020) note, students who pass through the gauntlet of required chemistry courses; students whose grades are not statistically different (but appear different because they were graded on a curve) have markedly different fates. Those who "pass" grade enter a hyper-persistent zone and are likely to do well in subsequent courses. Those that "fail" are rarely heard from again. One conclusion from such studies is that weed out courses are unfair and unnecessary barriers to inclusion (and learning), something of increasing significance as affirmative action programs come under attack (Velasquez, 2023).
The imposition of ill-conceived course requirements means that medical schools share the blame for the current state of biology education. A critical rethinking of their course requirements would benefit a wide range of students. The effort to improve, and monitor, student success and learning outcomes needs to be seen as important, acknowledged, and rewarded at the departmental level. Prioritizing student learning outcomes, as well as curricular relevance and coherence, has the added benefit of addressing the differentials in student preparation associated with class-based inequities (Lynch, 2023). If made a departmental priority, the various metrics of student learning outcomes can incentivize meaningful deliberations, provide actionable information for course and curricular modification, and code them as important rather than as distractions. For that to happen, medical and graduate school admissions committees must recognize that undergraduate biology degree programs should be to educate rather than to sort students. There are plenty of alternative ways to sort students (MCAT scores come to mind). While it is not the "business" of medical schools to help "non-pre-med" students, the phrase "first do no harm" seems particularly applicable in this arena (see this Harvard associated web site).
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