The undergraduate pre-medical system is broken. How did we get here and how do we fix it?
It is January 2018, and Emma T.* is at the north end of Yale’s campus for an organic chemistry lab class. She synthesizes a tawny powder of anthraquinone from benzoylbenzoic acid using a chemical procedure known as Friedel-Crafts acylation. After class, she hurries to physics office hours, where she spends the next two hours using Gauss’s Law to solve for the electric field that is a distance r away from an infinitely long rod with a linear charge density λ.
Why? Is she training to become a synthetic chemist or an electrical engineer? No — Emma T. wants to be a doctor, and, as she explains, “This is what medical schools want.”
Meanwhile, five miles south, in his first-floor office at the Connecticut Veterans Affairs Medical Center in West Haven, William Becker ’95 dons his white coat and makes the afternoon rounds. Some of his patients present with a low-grade fever, others with joint pain, but all of them seek something similar: to be seen by a doctor who will understand their problems and communicate the fix clearly. “Ninety percent of the job is having the humanistic qualities to talk with people, to comfort people, to communicate with people,” Becker says. “None of this is taught in pre-med.”
If you want to apply to medical school in the U.S., first you need to complete the so-called pre-med requirements, which include two years of chemistry with lab, one year of physics with lab, one year of biology with lab, biochemistry, calculus, statistics and psychology. That’s 20 classes — six more than are needed to major in English, seven more than physics and 20 more than to apply to law or business school, neither of which list a single prerequisite.
Doctors say this laundry list of classes is irrelevant to the reality of what they do. Students, who find the requirements unwieldy, are increasingly turning to other fields. What does this mean for doctors, those the system is meant to train, and for patients, those it is meant to serve? In its effort to cultivate the next generation of doctors, is the system of pre-medical education serving us well, and if not, what can be done to change it?
A VESTIGE OF A BYGONE ERA
In 1908, the Council on Medical Education — established four years prior to restructure American medical schools — tapped a then-unknown, 44-year-old educational theorist named Abraham Flexner to lead the reform. Flexner, who had no formal education in medicine, spent the next 18 months traveling across the country to evaluate each of its 155 medical schools.
What he found was a system in disarray. At one medical school, Flexner requested to see the laboratory facilities, and the dean proudly brought out a shoe box. At another school, Flexner noticed the library books were locked in cases. When he asked for them to be unlocked, neither the administrators nor the students knew how. Only the janitor carried the key.
In the early 20th century, American medical schools were churning out poorly trained doctors wholly unprepared for the demands of the profession, according to multiple books by medical historians. This changed abruptly, in 1910, when Flexner published the results of his study in a 346-page report, which detailed the disorder he had found and mandated a new set of standards for medical schools. Schools that could not adopt them were forced to close. By the end of the decade, 89 medical schools had shut down.
“The Flexner Report was a catalyst for the kinds of changes that transformed medical education by making it much more rigorous,” said John Warner, the chair of Yale School of Medicine’s Section of the History of Medicine. “The central aim was to ground medicine in the experimental laboratory sciences, which had created new ways of understanding the body and promised to transform things.”
The transformation of medical schools was so vigorous and complete that it percolated through the curriculum that preceded medical school, too. In his report, Flexner wrote that a “competent knowledge of chemistry, biology, and physics” was necessary “to establish a reasonable presumption of fitness to undertake the study of medicine.” This is the origin of the pre-med requirements.
Within 10 years of the Flexner Report, medical school educators began to worry whether the training had become too inflexible and scientific. Even Flexner had doubts, contemplating in a speech in 1929 whether medical schools were producing doctors that were “culturally thin and metallic.” Medical students voiced similar concerns, with one student at the time writing sarcastically in his diary, “When the first frog walks into my office, I will know exactly what is the matter with him.”
As the 20th century progressed, critics condemned the medical profession for failing to deliver better outcomes despite the scientific progress of the previous decades. The traditional model of medical education came under attack in the 1960s by progressive sociologists who condemned medicine as a failing enterprise because increased spending had not generated breakthroughs in the treatment of cancer and neurodegenerative diseases. In response, medical schools established humanities programs that offered new approaches to practicing medicine.
“Do I refer to my knowledge of any of those subjects in my day to day life when I’m seeing patients? Not really.”
—Anna Reisman, professor at the Yale School of Medicine
In the last decade, medical schools have cut the amount of classroom instruction and added more clinical work. However, for all the changes that have swept across medical schools, none have seeped into the pre-med curriculum at the undergraduate level.
As a result, the system of pre-medical education today remains largely identical to that established by the Flexner Report over a century ago — 11 years before the introduction of insulin, 32 years before the production of penicillin and 43 years before the discovery of DNA — and students are starting to speak up.
DIAGNOSING THE PROBLEM
Emma T. knew she wanted to become a doctor when she was 12. “When I was little I had a lot of stomach issues,” she recalled. “It was pretty traumatic. Some of my doctors were super nice. Part of my motivation was I wanted to be like them, to be able to help patients and make them feel safe and okay with whatever they were going through.”
In middle school, Emma gravitated toward the sciences. After 10th grade, she enrolled in a summer program at Brown University, where she learned how to handle a cadaver and take a patient’s medical history. “I really enjoyed it, and this is what cemented it for me,” she said. She was to become a doctor.
In 2017, Emma entered Yale College and noticed many of her peers signing up for a diverse spread of courses and activities. But her first-year experience was to be much more focused. “I talked to students who were applying to medical school and figured out what I needed to do,” she explained. “So, my first year I was taking chemistry, biology and math. I started working in a lab.”
It’s worth pausing here to consider that such is the story of many pre-med students. From the time they set foot on campus, they say they must fully dedicate themselves to a rigid lineup of courses and activities that leaves little room for much else. Jordan Young ’21 said his pre-med experience “has definitely taken away from the number of subjects I’m interested in but haven’t been able to take.”
The monopolizing coursework is compounded, doctors say, by the blurry and tenuous connection between the requirements themselves and the reality of practicing medicine. “Do you really need those classes to be a doctor? Do I refer to my knowledge of any of those subjects in my day to day life when I’m seeing patients?” asked Anna Reisman ’86, a professor at Yale’s medical school. “Not really.”
Becker is similarly skeptical. “When you first meet a patient, you’re taking a medical history, trying to understand their experiences, and then synthesizing that information into a treatment plan,” he explained. “This involves understanding the medical literature, yes, but there’s not much of a need to understand the foundational basic science.”
Dean of the Yale School of Medicine Nancy Brown ’81 believes otherwise. “Scientific knowledge is critical to the ethical and compassionate care of patients,” she said. “Without adequate scientific knowledge, we cannot provide safe and effective care.”
Here lies the crux of the debate over pre-med: To what extent is the emphasis on the basic sciences — subjects like organic synthesis and electric flux that Emma was learning her sophomore year — important in the daily lives of doctors? Proponents of the current curriculum argue that medicine is primarily a scientific endeavor, that medical advances are rooted in scientific advances, and for doctors to provide good care, they must be trained as scientists. The other side perceives medicine as a broader, more intimate endeavor. They believe there is something in caring for patients that transcends the basic sciences and cannot be learned through balancing double displacement reactions or conserving angular momentum.
Reisman wonders whether a curriculum that orbits almost exclusively around the basic sciences might be harmful in the way it distills the complexities of caring for people. She offered a timely example. “With COVID-19, and with health care in general, if doctors are not aware of the systems they work in, the biases that they have, the kinds of barriers people face, it’s impossible to provide good and equitable care,” she said.
“You look around the room and you know that one in five people are getting an A, regardless of how hard everyone works.”
—Ashna Aggarwal '20
But Stanley Goldfarb, a former dean at the University of Pennsylvania’s medical school, disagrees. In September 2019, he wrote a controversial op-ed in the Wall Street Journal criticizing medical school curricula for focusing too strongly on social justice issues. “My view is that our job as doctors is to treat illness,” Goldfarb told me. “Our job is not to cure poverty, our job is to cure pneumonia.”
Goldfarb’s adamance about training doctors purely in the basic sciences, it became clear, does not extend to the pre-med curriculum. Is organic chemistry necessary? “It’s a little hard to say,” he explained. “It’s like saying, does Shakespeare’s ‘Julius Caesar’ influence the way you think about contemporary politics? It’s hard to know. If you’re studying it, it becomes ingrained in your thinking in some way.” The benefit of organic chemistry, he argued, is in giving a good sense of the molecular complexity of the body. But does it need to be a whole year? And do you need an additional laboratory course in it, which is also a whole year? “You know,” he said, pausing briefly, “I don’t know.”
Though perspectives among doctors may vary, the research is unambiguous. Between 1951 and 1977, in the most robust study that has been conducted to date, Harrison Gough, a psychologist at the University of California, Berkeley, followed over a thousand college students as they matriculated to medical school and later became doctors. He wanted to see if success in pre-med courses was a prerequisite for success as a physician.
He found little evidence. Undergraduate science grades, Gough’s paper concludes, are “almost completely unrelated … to faculty ratings of general and clinical competence.” Then, he followed up the study with a series of psychological tests. He found that students who did better in undergraduate science courses were “narrower in interests, less adaptable, less articulate, and less comfortable in interpersonal relationships.”
Not only is performance in the pre-medical curriculum unrelated to performance as a doctor, it also appears to be, on an interpersonal level, harmful. As Becker noted based on his experience treating patients, we depend on our doctors when we are weak and vulnerable and need to be treated with humanity. As a result, it’s deeply problematic to rely on a curriculum that, in Becker’s words, “may inculcate a more biomedical view of the human experience as opposed to a humanistic one.”
THE COMPETITION THAT ABANDONS MANY
Students feel another problem acutely — that pre-med is cutthroat and grueling. Ashna Aggarwal ’20, who graduated summa cum laude and is taking a gap year before attending medical school, remembers her pre-med experience with a certain unease. “There’s a very stark difference between pre-med and other courses,” she said. “The workload is harder, it’s harder to get a good grade. It’s like the air is different.”
One student, who requested anonymity, said, “Pre-med feels like a crunch. It’s like a clock — a constant clock. There’s always something to do. There’s always a p-set, there’s always a quiz, there’s always a midterm.”
Emma agrees. Her sophomore year, when she was taking the organic chemistry lab and physics courses, she would wake up at 6 in the morning to squeeze in several hours of work before class. “I was spending every waking hour doing homework or in office hours or in lab,” she said. “Every aspect of my life became tangled up in pre-med.”
Pre-med student Wasil Ahmed ’21 acknowledges that it’s tough, but it’s for a reason. “Medicine is a super intense field,” he said. “It’s really high stakes, and it requires sacrifice. I don’t see why there wouldn’t be a reason for the training to be challenging sometimes.”
But pre-med students say it’s not the challenge itself that’s problematic — of course we want our heart surgeons to be competent in high-pressure situations — but it’s the culture that emerges from it. It’s no secret that pre-med courses are stressful. In an off-the-cuff survey of students sitting on Cross Campus one Saturday, when asked to describe pre-med in one word, six out of 10 said “cutthroat.”
“There’s always a cloud hanging over your head that you are competing with other people,” Aggarwal said. This sense of competition, she explained, arises from a curved grading scheme where only a fraction of students receive the best grades. She remembers the first day of her introductory biology class when the professor announced only 20 percent of the class would get an A. “So you look around the room and you know that one in five people are getting an A, regardless of how hard everyone works.”
Two introductory biology professors did not respond to requests for comment. Professor Mark Mooseker, the only one who did, said he does not use a defined curve. He explained that “for a given class we look at the performance range and make decisions about grade cut-offs.” Even so, he eventually admitted that cut-offs, like those Aggarwal mentioned, are “possible depending on the point distributions in a given year.”
According to Ahmed, the grading curves are also detrimental because they stifle collaboration. “In an exaggerated way, it feels like there’s an underlying animosity and tension” between pre-med students, he explained. “You’re less likely to help or ask for help. It’s just not good for learning, and it doesn’t help either party.” It certainly does not help patients either, because medicine at its core is a collaborative endeavor, and “to train every doctor in a non-team environment doesn’t make sense,” Ahmed said.
For some, the harsh grading schemes, the perception of being surrounded by competitive peers and the never-ending grind of work upon work become so crippling that there’s only one solution — dropping pre-med.
“The cruel irony of the whole thing is not just that the pre-medical preparation teaches stuff that students don’t need, it’s that a lot of that stuff is used to weed people out.”
—David Muller, dean for medical education at the Mount Sinai School of Medicine
In 2002, Stanford professor Donald Barr became interested in quantifying pre-med attrition after noticing that students who dropped it were more likely students of color and women. He conducted a study where he followed the trajectory of freshmen at Stanford who expressed interest in medicine. Of the initial 363 freshmen in the study, 294 applied to medical school. And of those who dropped, he saw that a disproportionate number were indeed women and students of color.
The student who requested anonymity, who is Black, said, “Every day on this campus, I walk into any space, and I instantly feel like I don’t belong. Pre-med just emphasizes that, because for so long, it’s somewhere you feel like you don’t belong.”
In a July 2020 article in Broad Recognition, Mia Arias Tsang ’21 describes how racism underpins medical education. This includes the content of the curriculum, which leaves out cases of medical abuse like the Tuskegee Syphilis Study and the forced sterilization of Black women, and presents science and medicine as neutral and divorced from their social implications. It also includes inflexible, punitive pedagogical practices — one of Arias Tsang’s professors refused to give her a one-day extension even when she was hospitalized, for instance.
“Most marginalized students struggle in STEM, and therefore in the science-heavy pre-medical track,” she writes. “They just do so silently. Our pain is only viewed as proof that we aren’t capable of the same things as our privileged peers. If we show any shred of humanity, it’s viewed as weakness, and we will be discarded.” Arias Tsang argues that racist and capitalist practices pit students against each other at the expense of collaboration and care, and overlook student well-being in favor of graded output. These make pre-med an exhausting, dehumanizing experience for all.
In January 2018, when Emma returned to Yale’s campus after a relaxing winter break, she returned with a sense of dread. “I just felt so much pressure,” she remembered. “It felt like I was staring down the barrel of a torturous semester. I don’t know exactly what triggered it. But I just felt like all at once it came crashing down.”
She had her first panic attack, which was followed by several days of intense mental and emotional distress. On most days she could not get out of bed. A week later, she unenrolled from Yale and was on her way home. She spent the ensuing semester reflecting on her choices and larger goals in life. “If I couldn’t do this,” she remembers thinking about her pre-med experience, “how could I possibly do medical school? It was really paralyzing for me because since I was 12, this was the path I had been following, and I was so certain of it for so long.” She paused to take a breath. “I just couldn’t take it anymore.”
IN SEARCH OF A CURE
Many of the doctors I interviewed thought the requirements could be reduced without compromising students’ scientific proficiency. According to Barr, the Stanford professor who has published several papers in favor of reforming the pre-medical curriculum, the eight semesters of general and organic chemistry with lab could be cut to two.
“Imagine a Venn diagram of chemistry and biology,” he explained. “There’s an intersecting set, which is the aspect of chemistry you need to understand how biological systems function. This is all you need.” The same applies to physics, math, and the other subjects that in obvious ways are peripheral to the practice of caring for patients. “You don’t need all of physics,” Barr said. “You just need a subset.”
David Muller, the dean for medical education at the Mount Sinai School of Medicine, agrees. Mount Sinai offers a special admissions program for sophomores that lets them matriculate without completing the pre-med requirements. Studies show no difference between the clinical performance of these students and those accepted to Mount Sinai from the regular admissions cycle who complete all the requirements.
“The cruel irony of the whole thing is not just that the pre-medical preparation teaches stuff that students don’t need, it’s that a lot of that stuff is used to weed people out,” Muller said. Aggarwal agrees: “If you can’t pour two chemicals in a beaker, are you gonna make a bad doctor? That shouldn’t be the message.”
This is not the message that the Yale School of Medicine admissions office advertises, Laura Ment, the associate dean for admissions and financial aid, said. “There is no simple formula for admission,” she explained. “Our process is holistic and contextual and carefully considers every part of the application” beyond performance in science classes. This includes the “interest and ability to work respectfully and collaboratively in diverse teams,” “sustained excellence across a broad range of activities” and other phrases such as “personal initiative” and “a commitment to … lifelong learning.”
Even if what Ment says is true, and academic performance in science classes is not the bottom line, does it make much of a difference? As online records suggest, the median GPA among accepted Yale medical students is around a 3.9, so academic performance must play an outsized role in admissions. But Yale is one of the best medical schools, so it’s entirely sensible that admissions is competitive. What’s more important and troubling is this: holistic admissions or not, the requirements persist. And as long as they remain in their current, bloated form, students like Emma are dropping out, so admissions offices are selecting from a smaller, less diverse pool of students than is possible.
But reforming the requirements is difficult. The first barrier is one of authority — there is no governing body that oversees medical schools and sets the requirements for entry. The closest thing to this is the Association of American Medical Colleges (AAMC), which in 2015 began advising medical schools to reconsider how they evaluate applicants by taking into account “core competencies,” such as teamwork, oral communication and ethical responsibility.
“The AAMC doesn’t mandate prerequisites,” Muller says. “They don’t have the primary responsibility of determining the requirements.” Instead, as Geoffrey Young, the director of student affairs and programs at the AAMC, explained, “Each medical school sets its own prerequisites.” So, Muller said, although most medical schools have the same requirements, “It’s kind of a Wild Wild West in that it is not overseen or governed in a way that one would think is necessary.”
In this system where the primary overseer has no power and the constituents shirk their own, there’s another difficulty: surmounting vested interests. As Muller explained, “When you create a system where chemistry and physics are the courses that everyone has to excel in if they want any hope of becoming a doctor, who’s got influence on campus now?” It’s undeniable that introductory chemistry and physics courses are as popular as they are not because 300 students will major in chemistry and physics each year, but because 300 pre-meds have to take them. As course enrollment balloons, these departments are given, according to Muller, “enormous resources because people are hammering their door down to get into their courses.”
But the biggest problem, it becomes clear, is a cultural one. Because for a reason that is difficult to articulate or impossible to find, performance in undergraduate science courses remains tethered to performance as a physician in the public imagination. Reputable studies show we are misguided. Doctors say so as well. There is no evidence that the cumbersome course load so deeply rooted in the sciences is producing better doctors. Instead, what it seems to be doing is keeping out good people — people from diverse backgrounds who are greatly underrepresented in the profession, people we need as this country sees an ever-growing shortage of primary care doctors. As students like Emma decide to drop the pre-med track, society loses future phenomenal, big-hearted, devoted doctors.
During her semester at home, Emma took a job at a local bakery. Her responsibilities included baking and frosting cupcakes each morning, staffing the front desk and helping couples design their wedding cakes. “That experience helped me recognize what was important for me in life and what things really mattered,” she said, pausing briefly to reveal a smile. “It helped me realize that there were ways other than medicine or status or how much people respected your resume that could make me happy.”
*The student requested a pseudonym to protect her privacy.