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.
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, Flexner(4) 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.
What Is the Purpose of the Premedical Curriculum?
In 1926, Capen(5) 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, Capen(5) 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, Furstenberg(7) 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, Gellhorn(12) 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 Coles(14) 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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– James E. Dalen, MD, MPH and Joseph S. Alpert, MD
This article was originally published in the February 2009 issue of The American Journal of Medicine.
