Humanizing the MCAT

For July 2020, some envision a new type of doctor entering the workforce: One who may not write very well but has extensive biochemistry knowledge, has a solid grasp of behavioral and social sciences, and has critical analysis and reasoning powers never seen before in the halls of medicine.

A 21-person Association of American Medical Colleges committee began the preliminary work on creating this vision three years ago, and the panel's recommendations for revising the Medical College Admission Test will be put to a vote during a Feb. 15-16 meeting of the AAMC board. If approved, a new test will be built and would be expected to be ready for students to take in 2015.

Some say the new test may replace the stereotypical med-school applicant pool from the driven, Type A personalities who know just about everything except how to relate to other people with a new breed of student full of empathy and compassion. Others say it may lead to the Type A's being better trained to deal with others who don't match their intellect, but at the expense of either pushing nonscience majors away from considering medicine or forcing them to take five years of undergraduate schooling in order to squeeze in the required coursework.

And then there are those who say, “Relax, it's just a test.”

The effort has been dubbed “MR5” because, according to the AAMC, this is the fifth comprehensive revision of the MCAT since its original version was used in 1928. The current edition has been in use since 1991, and it's likely that a revised test will be used until 2030. While people are generally aware of the test's strengths and limitations, there appears to be a desire to use it for something deeper than just measuring a student's ability to memorize scientific facts.

Dr. Darrell Kirch, the AAMC's president and CEO, touched upon this in his address at the organization's annual meeting this month.

“The MCAT exam is certainly a reliable tool to measure cognitive ability—that is, ‘brightness'—in certain areas, but we all know how little it tells us about the attitudes, values and experiences that may make an applicant truly among the best,” Kirch said in his speech.

“Our own AAMC public opinion surveys show this dichotomy. While the people we serve have a high level of confidence in the medical knowledge of our graduates, a significant percentage of them express real concern about the bedside manner of the doctors we produce. In essence, the public is more confident in our ability to bring the ‘brightest' to medicine than in our ability to find and educate the ‘best.'”

Recommendations for the new exam call for eliminating a required writing sample, and creating four test sections that would cover biological and biochemical foundations of living systems; chemical and physical foundations of biological systems; psychological, social and biological foundations of behavior; and critical analysis and reasoning skills.

The last two sections would be new additions to the test and, according to an AAMC MCAT “preview guide,” the first three sections of the proposed test are organized around “big ideas” in science and emphasize “deep knowledge of the most important scientific concepts over shallow knowledge of many discrete scientific facts.” The preview guide also states how, “Before drawing a conclusion, scientists identify key assumptions and evaluate evidence relative to their claim.”

The fourth section measures an applicant's ability to do so.

In addition to the main panel working on the revisions, a smaller group formed an “innovation lab” that last month issued its own recommendations about what “personal competencies” a new test should measure in order to predict successful performance in medical school. These six competencies were identified as integrity and ethics; reliability and dependability; service orientation; social, interpersonal and teamwork skills; desire to learn; and resilience and adaptability.

According to Karen Mitchell, MCAT senior director and staff leader of the MR5 initiative, 90 outreach events were held, and the committee received plenty of recommendations.

“There certainly was a wide range of views of what the MCAT should do and test for,” Mitchell says, including those who thought medical-school students should be required to have advanced scientific knowledge upon arrival and those who sought a more “well-read and well-rounded” applicant pool who could be taught the science they need to know when they got there. “I think certainly one of the big messages the test is communicating is to have balanced preparation,” Mitchell says, adding that the new MCAT will require applicants to demonstrate “not only mastery of the content, but being able to use that knowledge” with scientific problem-solving and statistical analysis.

Dr. George Thibault, president of the Josiah Macy Jr. Foundation medical education advocacy group and former chief medical officer at Brigham and Women's Hospital in Boston, says he's encouraged by the work of the MR5 panel, but he thinks the test's potential impact needs to be kept in perspective and that the revised MCAT cannot be seen as the “end all and be all” in determining how to develop a physician workforce that will meet society's near-future needs.

“I don't think the test alone will be a sufficient tool to bring about the change. … Tests are not all that good or powerful—no matter how well-devised,” Thibault says. “Revision of the test is a small piece of a holistic process.”

Richard MacDonald, professor of biochemistry and molecular biology at the University of Nebraska Medical Center, Omaha, has chaired the UNMC College of Medicine admissions committee for more than 15 years and says the MR5 recommendations validate his panel's decisions to discard the writing sample and to list biochemistry and genetics courses as prerequisites for application. MacDonald,

who has a doctorate in biochemistry, describes the proposed revision as having “a great deal of biochemistry fused into the exam,” and he notes that this could have a subtle-but-significant effect.

MacDonald says that many medical-school applicants take the MCAT after their junior year of college and then take biochemistry their senior year, but now “it would behoove any student who would sit for the MCAT to take biochemistry before.” He thinks this schedule shift could force some psychology or nonscience majors—such as fine arts, literature, music or philosophy students—to extend their undergrad tenure to five years or to rethink their plans to go to medical school—which would defeat the purpose behind some of the revisions.

MacDonald says it's difficult to assess, but admission committees want to see “evidence that students can look beyond themselves” with a sense of altruism and “awareness that there is a bigger society of which they are a part.”

“They all have to have some emotional intelligence,” MacDonald says, adding that the high-intelligence, poor-people-skills medical student is not a stereotype that can be applied broadly to the applicant pool at his medical center, “but we do reject applicants that fit that profile—we need to see applicants interacting with others.”

Though he adds that these applicants might be a better fit at schools where more physician-scientists are trained—even students on that career path “still need to be motivated by compassion deep in their hearts,” he says.

Colin McCluney is taking time off between his third and fourth years at the University of Washington School of Medicine in Seattle to serve as the American Medical Student Association's education and advocacy fellow. As a music major, McCluney—who plans on going into family medicine—took a “nontraditional” path to medical school, starting at age 30. He explains that he did well on his MCAT, but his grade-point average did not excite admission committees. So he went back to school to take more science courses, raised his GPA and “made a ‘more personal' personal statement that grabbed people's attention.”

McCluney gave some cautious praise to proposed revisions.

“I think attempts to make it more cultural and socially aware are very important and laudable, but I think just revising the MCAT is not going to produce the best physician workforce that we can,” McCluney says. “I think this is a small step in the right direction—there is more to being a good physician than great knowledge of science and verbal reasoning skills. … It will be interesting to see how this plays out. Certainly, if it winds up discouraging nonscience majors, it will be a step in the wrong direction.”

MacDonald says UNMC gets more than 1,500 applications, of which some 400 are interviewed for seats in a class of 130. He explains there was no way to read all the writing samples and that it was hard to link a subjective assessment to a standardized score.

Dr. Kenneth Ludmerer, a professor of medicine and medical history at Washington University School of Medicine, St. Louis, agrees that the removal of the writing sample is no great loss. “The intention there is that maybe we can tell something about them by the way they write, but being a good writer doesn't necessarily make you a caring person,” he says, adding that studying the humanities doesn't prove your humanity nor does a long list of volunteer efforts prove altruism.

“You can't do it by saying we want to see evidence of volunteerism and activities. Because they'll just say, ‘You want to see activities? I'll fill in six pages of CV (curriculum vitae) for you with clubs and activities I participate in.' ”

Ludmerer, who is on the Accreditation Council for Graduate Medical Education board of directors and served on the Institute of Medicine committee on medical resident work hours, says one of the strengths of the MCAT is that it's “an equalizer,” helping to put students on an equal scale even if they come from an institution “where an A might be different than an A somewhere else.”