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Undergraduate Preparation for the Health Professions and the Revised Medical College Admissions Test
In 2009, a joint committee of the Howard Hughes Medical Institute (HHMI) and the Association of American Medical Colleges (AAMC) released the report Scientific Foundations for Future Physicians (SFFP) (AAMC–HHMI Joint Committee 2009). The SFFP report focused on the natural science and quantitative “competencies” needed for the preparation of successful physicians. The report included recommendations for both undergraduate preparation in the natural sciences and mathematics for medical school and for medical education itself. The SFFP report was used to guide the review and revision of the Medical College Admission Test (MCAT) by AAMC’s MR5 Committee. The AAMC adopted the recommendations of the MR5 Committee in February, 2012.
The SFFP report explicitly framed its arguments in terms of what knowledge and skills students should acquire in the natural sciences and mathematics and what they should be able to do with that knowledge and those skills—in short, the competencies that students should be prepared to demonstrate if they are to be successful physicians. The focus on competencies as a method of articulating student preparation was made intentionally. Colleges, universities, and medical schools should be able to be innovative in helping students demonstrate these competencies and not be constrained by the traditional requirements formulated in terms of courses: one-year of organic chemistry or a semester of neuroscience, for example. In addition to giving educational institutions the freedom to construct innovative programs, the formulation in terms of competencies is much more explicit in explaining what students should know and be able to do. A year of organic chemistry, though there is a general consensus of what that means, still might cover a multitude of different topics—only a few of which might be relevant for future physicians.
The SFFP and MCAT are far from being pioneers in the use of competencies to express learning objectives. In engineering, the ABET accreditation program (ABET 2009) moved to a competency model in 2000. More recently, the report Vision and Change in Undergraduate Biology Education (Brewer and Smith 2011) articulates the objectives for undergraduate biology majors in terms of competencies. The US Medical Licensing Exam has moved to a competency model by asking examinees to use their science knowledge to reason about medical problems rather than simply regurgitating facts. In K–12 education, the recently released Framework for K–12 Science Education (National Research Council 2012) and the accompanying draft of the Next Generation Science Standards (http://www.nextgenscience.org/) explicitly link scientific content knowledge with science and engineering practices, which demonstrate the ability to use the content knowledge in a variety of ways.
A 2002 National Center for Educational Statistics report, Defining and Assessing Learning: Exploring Competency-Based Initiatives (Jones, Voorhees, and Paulson 2002), defines a competency as “a combination of skills, abilities, and knowledge needed to perform a specific task.” In the broader context of undergraduate education, “Competency based initiatives, then, are those purposeful actions undertaken by postsecondary institutions directed at defining, teaching, and assessing competencies across their system.” (Page vii).
The report goes on to describe methods that help students become competent. “Competencies are the result of integrative learning experiences in which skills, abilities, and knowledge interact to form bundles that have currency in relation to the task for which they are assembled” (Jones, Voorhees, and Paulson 2002).
To show how a competency model informs the natural sciences content of the revised MCAT, we need to first describe the changes that AAMC is implementing. At a structural level, the revised MCAT will consist of four sections:
- Biological and Biochemical Foundations of Living Systems
- Chemical and Physical Foundations of Biological Systems
- Psychological, Social, and Biological Foundations of Behavior
- Critical Analysis and Reasoning Skills (AAMC 2011)
New to the revised MCAT is the section on the psychological, social, and biological foundations of behavior (see the Frazier and Twohig article in this issue). In short, this new material reflects the increasing recognition that in many cases the behavioral and social components of health and disease are just as important as the molecular and physiological components.
The Critical Analysis and Reasoning Skills section is a direct replacement of the current Verbal Reasoning section and will ask the students to read and answer questions about passages from the humanities and social and behavioral sciences. All the information needed to answer the questions will be provided in the passage.
The revised MCAT will have more biochemistry and cell and molecular biology than does the current exam. The biochemistry will be limited to that covered in a one-semester foundational course as recommended by the American Chemical Society’s guidelines for undergraduate chemistry programs (Committee on Professional Training 2008). The cell and molecular biology concepts will be at the level taught in many introductory biology courses across the country. These changes were made in recognition of the growing importance of knowledge of the biochemical and cell and molecular biology basis of health and disease in the practice of medicine.
- The biological, chemical, and physical parts of the revised exam will be built around five foundational concepts, which play the role of the competencies laid out in the SFFP report. Those five concepts are
- Biomolecules have unique properties that determine how they contribute to the structure and function of cells and how they participate in the processes necessary to maintain life.
- Highly organized assemblies of molecules, cells, and organs interact to carry out the functions of living organisms.
- Complex systems of tissues and organs sense the internal and external environments of multicellular organisms and, through integrated functioning, maintain a stable internal environment within an ever-changing external environment.
- Complex living organisms transport materials, sense their environment, process signals, and respond to changes using processes understood in terms of physical principles.
- The principles that govern chemical interactions and reactions form the basis for a broader understanding of the molecular dynamics of living systems. (AAMC 2011, 10–11)
Each foundational concept is supported by a listing of appropriate content topics, which we will not describe here. (In the SFFP report there is an intermediate layer of learning objectives associated with each competency. The SFFP report consciously avoided listing specific, detailed content topics.) The list of “allowed” MCAT content topics was generated by having current MCAT science topics rated by medical school basic science faculty, residents, and medical students and correlating those topic rankings with what undergraduate faculty report is commonly taught. The details of the process and the complete list of content topics are available through the AAMC web site: https://www.aamc.org/initiatives/mr5/.
In addition to science content topics, the MCAT will test scientific inquiry and reasoning skills (SIRS):
- Knowledge of Scientific Concepts and Principles
- Scientific Reasoning and Evidence-Based Problem Solving
- Reasoning about the Design and Execution of Research
- Data-Based and Statistical Reasoning
Note that the quantitative skills focus on reasoning about data using statistics and other mathematical tools. These skills are just those that are taught—sometimes implicitly rather than explicitly—in the laboratory components of most introductory college and university science courses. Students will not be expected to have taken courses specifically in research methods.
These skills will not be tested in isolation. Students’ competencies in the natural sciences and quantitative reasoning will be tested by writing questions that ask students to apply one or more of the SIRS skills and their content knowledge to answer questions about passages that describe scientific problems in the context of living systems.
Implications for Undergraduate Education
How will undergraduate institutions help students who are interested in medical careers develop these competencies? As a first approximation, undergraduate faculty need not do much more than make sure that students have experience using the scientific inquiry and reasoning skills described above to solve scientific problems. In addition, chemistry and physics faculty should give students practice in applying the concepts of chemistry and physics to situations that apply to the understanding of living systems. Education research has shown (Bransford, Brown et al. 1999) that students have difficulty applying what they have learned in contexts different from the context in which the material was first learned. Of course, this transfer of learning is something we want our students to master, so having them practice applying their knowledge and scientific reasoning skills in a wide variety of areas is a virtue in its own right.
As mentioned previously, the focus on competencies allows colleges and universities to think about creative curriculum innovations such as integrated science courses. SFFP undergraduate competencies, though focused on future physicians, are broadly applicable for all prehealth students and in fact, in the opinion of the authors should be part of the education of all science students.
Implications for Medical Education
The move to competency-based education in the undergraduate learning environment is wholly aligned with current pedagogical approaches to undergraduate medical education and graduate medical education. Medical schools anticipate several advantages to an undergraduate science experience that is constructed and defined by competencies rather than by courses.
First, medical schools themselves have almost uniformly embraced competencies as a strategy for identifying and assessing the knowledge, skills, and attitudes needed to be a successful physician. Scientific advances that increase our understanding of disease and therapy are occurring at a rapidly accelerating rate. Medical schools design educational and assessment programs to ensure that their graduates have mastered the ability to apply scientific concepts to the evaluation and management of patients today as well as to sustain their competency in science-based care over careers that frequently span four or more decades of scientific discovery. They realize that their focus must be primarily on scientific competency: integration and application of scientific concepts and critical reasoning skills, rather than the recall of scientific facts. Undergraduate students whose mastery of scientific concepts is described using a competency framework will fit into the continuum of learning that currently defines undergraduate medical education and graduate medical education.
Second, many medical schools have moved from discipline-based courses as the teaching strategy for biomedical sciences to integrated courses including biomedical, social, and behavioral sciences along with clinical application. Competencies, designed to focus on the integration of the knowledge and on the attitudes and skills necessary to perform in a desired manner, play a major role in the design of these integrated courses and the assessment of students taking these courses. For example, courses such as the University of California–San Francisco’s integrated Brain, Mind, and Behavior course will likely incorporate concepts from neurophysiology, neuroanatomy, neuropharmacology, neuroradiology, neurology, and psychiatry to help students develop competencies such as reading the scientific literature relevant to these fields as well as evaluating and managing patients with neurologic or psychiatric complaints. A competency-based framework will allow schools to define more precisely the background students must have to succeed in their unique integrated curriculum.
Third, competency-based undergraduate science education and competency-driven MCAT exams may help standardize the preparation of students matriculating into medical schools while also providing some flexibility in coursework. Current medical school entrance requirements focus on time in courses (i.e., one year of physics, one year of organic chemistry with a lab) and grades as the only evidence of adequate preparation for the medical school curriculum. Unfortunately, courses, even those using the same textbook, can vary substantially from institution to institution, leading students to believe that they have mastered the content needed to successfully navigate a given medical school’s curriculum because they have taken a course with the right name. Additionally, concepts in foundational sciences needed to succeed as a health professional have expanded to include informatics and engineering (systems and biomedical), as well as social and behavioral sciences. If we continue to rely upon successful completion of an undergraduate course as the only acceptable evidence of adequate preparation for advanced study in medical school, we will quickly find our students unable to pursue anything other than medical school prerequisites during their undergraduate experience. This would constrain students’ abilities to pursue more in-depth experiences in biomedical sciences or any experience in fields not required for medical school preparation. The result would be a generation of physicians who do not have the diversity of thought and experience desired in members of the medical school and professional community.
Fourth, medical schools will be better able to align student preparation with the curriculum that best supports their school’s mission, vision, and values. Schools that aim to produce biomedical scientists may choose to require that their applicants demonstrate advanced competencies in core biomedical sciences so that they can focus their school’s curricula on cutting-edge science. Schools with a stronger focus on public health or community service may choose to require advanced competencies in fields relevant to these topics and accept core competency in traditional biomedical science.
The format of the new MCAT and changes in undergraduate science curriculum that follow will change medical school admissions, though not without some challenges. Medical schools will be able to define and disseminate their views on the competencies needed by students entering their curriculum. Students will be able to use this information to plan their undergraduate experiences. Admissions committees will be able to take a more holistic view of their applicant’s premedical preparation that will enable students to demonstrate that they have achieved a particular competency even if their transcript does not list a traditional course. For example, they may decide that there are many ways to demonstrate competency in core physics constructs relevant to the biomedical sciences other than taking a year-long physics course with lab. Until undergraduate institutions map existing courses to prehealth competencies, applicants and medical schools alike will need to do more due diligence about the content of courses listed on transcripts.
Putting it All Together—The Prehealth Pyramid
In viewing the preparation of undergraduates for the health professions, it can be helpful to have a big picture framework of what we are trying to accomplish. The prehealth pyramid displayed in figure 1 below aims to help visualize the complex relationships incorporated into the revision of the MCAT. The prehealth pyramid is designed to provide a coherent framework for the design of competency-based prehealth professions education. It is explicitly designed to apply to all prehealth students regardless of their eventual choice of graduate level health professions education. It may also be useful for those preparing for graduate education in the sciences.
The prehealth pyramid builds upon the traditional emphasis on the physical and biological sciences, recognizing the need for continuing updates. The behavioral and social sciences component can be viewed as essential content for the practice of the health professions. The behavioral and social sciences should incorporate an increasingly sophisticated biological understanding of human behavior and social interactions as applied to health problems.
The Scientific Inquiry and Reasoning Skills (SIRS) provide the glue that aims to hold these content components together. They include scientific and evidence-based thinking, study design and execution, and data-based and statistical reasoning.
The dotted lines are intended to imply an increasingly porous relationship between the traditional disciplines. The prehealth pyramid implies that health professions education should be built on a foundation of integrative sciences. Together these components of the prehealth pyramid are designed to produce a coherent whole that allows students to see the relationships between the disciplines.
The prehealth pyramid aims to assist health professions educators to build on a solid understanding including both the process and the content of the physical and biological sciences as well as behavioral and social sciences. Ideally this integrative approach will do more than prepare students for the new MCAT. It will help guide the transformation of undergraduate preparation for the health professions.
American Association of Medical Colleges. 2011. Preview Guide for MCAT2015. Washington, DC: American Association of Medical Colleges.
American Association of Medical Colleges–Howard Hughes Medical Institute Joint Committee. 2009. Scientific Foundations for Future Physicians. Washington, DC: Association of American Medical Colleges and Howard Hughes Medical Institute.
ABET. 2009. Criteria for Accrediting Engineering Programs. Baltimore: ABET.
Bransford, J. D., A. L. Brown, and R. R. Cocking, eds. 1999. How People Learn: Brain, Mind, Experience, and School. Washington, DC: National Academies Press.
Brewer, C. A., and D. Smith, eds. 2011. Vision and Change in Undergraduate Biology Education. Washington, DC: American Association for the Advancement of Science
Committee on Professional Training. 2008. Undergraduate Professional Education in Chemistry. Washington, DC: American Chemical Society.
Jones, E. A., R. A. Voorhees, and K. Paulson. 2002. Defining and Assessing Learning: Exploring Competency-Based Initiatives NCES 2002-159. Washington, DC: National Center for Education Statistics.
National Research Council. 2012. A Framework for K–12 Science Education: Practices, Crosscutting Concepts, and Core Ideas. Washington, DC: National Academies Press.
Robert C. Hilborn is the associate executive officer at the American Association of Physics Teachers; Catherine R. Lucey is a professor of medicine and vice dean for education at the University of California, San Francisco School of Medicine; Richard K. Riegelman is a professor and the founding dean of the School of Public Health and Health Services at The George Washington University.