Science prerequisites for medical school: (uh!) what are they good for?

Last week, in response to a New York Times article about a medical school with a program to admit students who have not taken physics, organic chemistry, or the MCAT, Chad Orzel expressed some qualms:

On the one hand, I tend to think that anyone who is going to be allowed to prescribe drugs ought to know enough organic chemistry to have some idea how they work. On the other hand, though, I would shed no tears if the pre-med physics class disappeared entirely-- most of the students resent having to take physics, and I'm not wild about being used as a weed-out course for somebody else's major program, which is a combination that easily turns into a thoroughly miserable experience for everyone. ...

Still, I'm a little uneasy about people getting to be doctors without taking science in college at all ... I suspect Mount Sinai has good results from this program because it's just about the only one going, and they get their pick of the very best students, who are able to pick up what they need from "summer boot camp." I'm less comfortable with the idea of making this a general policy-- a lot of the students I see struggling in pre-med physics are struggling because of things that would not be positive features in a doctor.

Nowadays, in my capacity as a philosophy professor, I'm actually teaching more chemistry and physics and biology majors, and fewer pre-meds, than I did back in the days when I was a chemistry graduate student. If I recall correctly, all but one of the undergraduate courses for which I was a teaching assistant in my chemistry program were part of the pre-med sequence, including not only first term organic chemistry and the qualitative analysis laboratory course, but also physical chemistry for pre-meds.

I think it's safe to say that the pre-meds were not always enthusiastic about the material we were trying to teach them.

Indeed, "What am I ever going to use this for?" was an oft heard question in those courses:

"When am I ever going to need to balance a redox reaction when I'm performing brain surgery?"

"How is knowing the difference between SN1 and SN2 reactions going to help me deliver babies?"

"What the hell does understanding how a refrigerator works have to do with orthopedics?"

I'm not that kind of doctor (nor do I play one on TV), so I'd probably refer these questions to people like PalMD or Orac or Pascale. (I will note that I recognized some nice chemical content in Pascale's post on salt and bloat, so I'm guessing that she wouldn't be writing any pre-meds a doctor's note to excuse them from chemistry altogether.)

The course prerequisites for medical school, however, have been set by the medical schools. One would hope that they have some good reason for setting them -- whether because they impart information and skills directly applicable in the work of being a physician, or because they impart information and skills that will be assumed in the coursework to be completed in medical school, or because they expose students to patterns of thought and problem-solving strategies that are expected to be useful to them in tackling the medical problems they will be tasked to address.

It's also possible, I suppose, that medical schools have selected the slate of courses required for admission in order to thin out the numbers of applicants that they will have to sift through to build a class. If that's the case, though, one wonders why they would choose just the hard-enough-to-get-rid-of-the-chaff courses that they did. Why Newtonian physics and not quantum mechanics (or hell, even E&M)? Why organic chemistry or "baby P-chem" rather than the thermodynamics course the chemistry majors have to take (followed by the quantum chemistry course those chemistry majors need to take)?

If you really want to weed them out, why not a serious first order logic course?

I, personally, think the whole philosophy of the "weeder" course is problematic. Moreover, I suspect that setting up intro science courses to "weed out" some large proportion of the students taking them from moving on to the next course in sequence (or to the professional program for which these courses are prerequisites) probably does as much to undermine students' understanding of the course material, or enthusiasm to engage with it, as the objective difficulty of the material itself.

Maybe if medical schools have more people interested in applying to them than they know how to handle, they should do their own dirty work as far as screening applicants goes. The alternative is to create legions of physics and chemistry professors who would be just as happy not to have to deal with premeds at all.

Myself, I feel more comfortable with a doctor whose brain is hungry for knowledge, someone who wants to learn not only because it means picking up useful information about our world and how it works, but also because it's fun. I have no idea if this kind of attitude tends to lead to better physicians or more successful medical students, but my hunch is that it may lead to human beings who are better prepared for life in the fullest sense.

That seems like an important thing even for premeds.

27 responses so far

  • Schwa says:

    As a medical student, I think that physics and chemistry are definitely important to understanding what we are doing. Memorizing a billion diseases and drugs is indispensible, but frankly, if you're looking at a CT or ultrasound image, and have no meaningful idea of how it was produced, then go on to a diagnosis and treatment whose chemical basis is more or less mysterious to you, you may as well be a witch doctor. People complain about cookbook medicine, and the way to get away from that is intimate knowledge of biochemistry and physiology of the system you're working with. It's obvious that someone who prescribes drugs should know enough chemistry to follow the pharmacology that justifies their use, but physics is just as crucial to understanding the tools of the trade.

  • Pat Cahalan says:

    > If you really want to weed them out, why not a serious
    > first order logic course?

    I'd think this is a good idea for anyone who wants to get a degree in any science.

    • Janet D. Stemwedel says:

      And yet, where did I take mine? In a doctoral program in philosophy.

      • ewe-man says:

        The greatest class none* of my students have taken before professional school that has the capacity to save their butts in the trenches is an upper-level philosophy of science or philosophy of biology course.

        *okay, maybe ten out of 700+.

      • Pat Cahalan says:

        Disclaimer: I never took a formal logic course in a Phil track.

        At my alma mater (Loyola Marymount University), there was no requirement in the core for Logic 101 or equivalent. The university Honors program (of which I was a member) had a requirement, but if you were a science &/or engineering major it was typically waived.

        The first course in mathematics theory construction was largely an introduction to formal proofs; basically first-order logic. It more or less counts, although math logic waves over the questions of ontology and you can largely ignore the problem of induction, math being axiomatic and all that (metamathematics came later). It helped quite a bit that I read Aristotle in high school.

    • Snarkyxanf says:

      What do you mean by "serious first order logic course"? That could be (at the least), a "how to use logic", "intro to the mathematics of logic", or "the philosophy of logic", which would be drastically different courses.

    • Vicki says:

      I would delete at least part of that sentence: "I think this is a good idea for anyone" and that first-order logic should be required for all college students, right up there with English comp.

      • Pat Cahalan says:

        Fair enough.

        More generally, I've argued before that a decent first-order logic course belongs in the high school curriculum. You shouldn't have to be on a debate team to understand what a warrant is.

    • Dan Hicks says:

      As a philosopher of science and teacher of formal logic classes, I think statistics is much more useful than formal logic, both in general and for practicing scientists. The tools developed in a first formal logic course can only be applied to a very rarefied class of arguments in English. I used to give an assignment where I'd give my students a bit of argumentative writing (an op-ed or opinion piece) and have them symbolize it; I stopped doing that when I realized how messy most of the arguments we encounter `in real life' really are. Even professional philosophers writing on blogs (the examples I have in mind are not on this blog!) will use ambiguous language and implicit premises.

      • Pat Cahalan says:

        Without a decent grounding in logic, it's damn easy to misunderstand really bad arguments. Given that science is evidence-based, this seems to be the foundational foundation :)

        Yes, particularly for any field that depends upon statistical significance, probs & stats is horrifyingly under-emphasized, but you can't recognize a bad statistical argument if you don't understand logic *and* statistics. Walk, then crawl! We'll get to running later...

  • At some institutions, departments receive credit for the number of students they teach (i.e., they are allowed to 'claim' that tuition in terms of accounting for how much money they bring into the institution). I doubt some departments want to 'lose' those captive tuition dollars.

    • Janet D. Stemwedel says:

      Undoubtedly, there are economic factors that have helped entrench the current system. But it strikes me that such entrenchment is a bad reason not to examine prereqs periodically to see if they make sense for the students (or the professional programs) they are supposed to serve.

      Also, the economic factors do shift from time to time. My own university used to be set up so that "resources follow enrollments" -- until the state of California decided it couldn't pay its share to educate as many students as we were enrolling, and accordingly throttled admissions. Now, we are told that "resources follow majors" -- which means our numerous general education courses need to be reimagined as a way to lure in more philosophy majors.

  • Snarkyxanf says:

    Admittedly, a doctor is unlikely to do many physics or chemistry problems, but I should hope that they are aware that the rules and guidelines they memorize are for chemical or physical *reasons*.

    I find that knowing the origin of a rule, even if only hazily, makes it easier to remember and apply.

    I would like my doctors to know something of philosophy, literature, art as well. Their patients are humans, after all.

  • Jim Thomerson says:

    When I was at Texas Tech, preparing to go do PhD in Zoology at Tulane, I read the catalog and found that I was supposed to have had a laboratory course in organic chemistry. Tulane has a med school, so I knew what the organic chemistry course would be like. I looked for an escape route. Tech offered a one semester course with lab, Organic Chemistry for Agriculture Majors. I took same and made a B. The text was about 3/4 in thick. At Tulane, the department chair asked me, "Young man, have you had a laboratory course in organic chemistry?" "Oh, yes, sir, I surely have!", and the rest is history.

  • PhD student says:

    "Myself, I feel more comfortable with a doctor whose brain is hungry for knowledge, someone who wants to learn not only because it means picking up useful information about our world and how it works, but also because it’s fun."

    I agree with this. What you get out of your course work is what you put in. Even as a grad student, I'm surrounded by people who moan about taking a class when they know their degree hinges around their thesis.
    Ok, fine. I really hated my environmental policy requirement course (the teacher and TA were horrible lecturers), but the material itself was really cool. And knowing all of that came in handy when talking about farming practices with my distant uncle at a family reunion. The point of it is, as a scientist it's good to be well rounded. I don't always understand physics blogs, but that doesn't mean I don't try to read them. But then again, I find most things related to any science interesting.

    I think that if pre-med students don't understand why they need a steady base of the sciences, then they have no true respect for the field into which they are entering. If you don't understand the foundations of what medical practice is based upon then you don't belong there, imho.

  • D. C. Sessions says:

    I can't get you Orac, but Dr. David Gorski has addressed this at Science-Based Medicine: http://www.sciencebasedmedicine.org/?p=6366

  • IanR says:

    I guess I would make a few points points:

    I think it is important for people in medicine to be scientifically literate and use scientific thinking. That is, it is important for them to take data, evaluate it, and use it to make a conclusion, while discarding alternate hypotheses. Does the MCAT test for these? Hard to say.

    Looking at the paper, it looks like Mt. Sinai is a "feeder" program into the medical school. The students still take "Principles of Organic Chemistry and Physics Related to Medicine," presumably a less content-focused version of organic chemistry and physics than the traditional courses. I highly doubt that most colleges and universities would gut their chemistry and physics departments to serve a soley pre-medical focus; most serve multiple consituencies including chemistry and physics majors and many schools cannot offer different types of organic chemistry and physics courses for economic reasons.

    And my last point: These are the only students in the United States taking this path, meaning that they have a very unique history. It does not immediately generalize that the average English major would be successful in medical school if this were done nationwide.

    To be honest, I'd prefer to have a physician who was scientifically literate in more than just medicine.

    • Schwa says:

      I also happen to teach MCAT prep classes. The MCAT sort of tests for these things - the way the test is presented is as a passage-based test, so if you recall the reading comprehension bits of the GRE or SAT, it's the same sort of "Here's a big block of text and some related questions" thing. The difference is that MCAT questions will ask the student to apply one of the bits of knowledge on their list of stuff that they test to make some statement about the thing that's being tested (e.g. a passage might describe the basic functioning of a manufacturing process, with a brief description of the machining steps and a diagram of a hydraulic stamping machine. A question might ask how much work the machine does with each press, given its dimensions and the pressure it exerts on each piece).

      So, the way the MCAT is designed, it's possible to get a decent score by just memorizing gigantic numbers of disconnected facts, which is itself a useful skill in medical school. Unless you're some kind of savant, it's only really possible to get a stellar score if you have some appreciation of the interplay of different ideas, from atomic structure and fundamental forces to basic chemical reactions to cellular biochemistry to overall physiology.

  • PalMD says:

    Quick response from north woods:
    I love my premed classes, but i'm a freak.

    There is so much drive to accept unscientific practices in medicine, i think a strong science background may help to prevent this from becoming even worse. There are undoubtedly tweaks that could be made to the system, but knowing how a cell membrane organizes and why is nice.

    Once you decide to deliver babies, you might not need to know an sn1 from an sn2, but your physics class might help inspire you to specialize in radiation oncology, which is pretty cool. Must sign off of dial up now.

  • David says:

    The "weeding out" aspect is multi-dimensional. Not just weeding out people who don't have the academic skills (learning vast quantities of information in a short time, mastering certain kinds of problem-solving) but also there is a social filter in place. These courses eliminate those people who don't have tolerance for hard work, or who are only willing to work hard when it's in their immediate interest. These courses select for people who can follow instructions even when they may not personally care to.

    When you call your doctor at 1 AM, you want somebody who will get up and go, if needed. Not somebody who whines about your problem not being relevant, or about how hard they're working.

    I do believe that a large fraction of medical education involves socialization to the profession.

    That's not to belittle the science content. But physicians really don't need to know most of what is taught in o-chem (synthesis methods). A different o-chem course, more biologically oriented, but still strenuous, would make more sense. More logic, more statistics, and more lab work would all be good additions to the pre-med curriculum (in my opinion).

    I am a physician working full-time for a pharma company. I was in practice for many years before moving to industry.

  • Miedvied says:

    Those basic science courses are directly applicable to understanding modern medicine on anything beyond a rote-memorization level. All those same students who gripe about orgo, physics, etc.. walk into Biochemistry, are floored because *this is medicine, oh gosh, how cool* and then gripe about how they can't understand the material well enough because they weren't "taught" (read: spoon-fed) physics, general chemistry, and organic chemistry.

    Oh, the science matters, quite directly. It's just that biochem is not yet widely required of pre-meds, and med school biochem is extremely light, qualitative, and quickly skimmed over. As biochem reqs become more common, you'll see increasingly more pre-meds lament their previous negligence in their science studies.

  • Pat says:

    I took my chemistry ages ago, but I can't for the life of me remember how anything from organic or physical chemistry played into any of the biochemistry or biology courses. Nor do I ever have to reference principles from either of those courses in the physiology and pathophysiology courses I currently teach, even at the graduate level. More than that, I can't imagine what I *could* transplant from organic or physical chemistry into those courses that would increase the students' comprehension, or even my own.

    I have seen presentations that applied organic and physical chemical principles to pharmacology, and they were indeed impressive. They were about drug design and synthesis, by chemists and for chemists. But I can't imagine a doctor finding them useful for understanding how the drugs work or are metabolized. We wrestle with this same set of questions as regards biology majors.

    In my sardonic moments, I ask myself whether *anybody* outside the chem major needs organic chemistry. I'm forced to think that its ubiquity in biology and medical requirements stems from something else, and survives because most people writing those curricula enjoyed the class themselves and feel no need to question its inclusion. I certainly found it a lot of fun, sort of like spending two semesters doing challenging jigsaw puzzles. But that doesn't mean it is a worthy use of my students' time and money.

  • Peter R. says:

    1) There would be far fewer chemistry professors (albeit happier) if pre-med students did not take chemistry. Chemistry majors are always, and have always been, the minority of students in general and organic chemistry.

    2) The idea that chemistry is a "weed-out" course is misleading, because it is not the chemistry instructor's job to choose who goes to medical school. Our job is to determine how well our students learn chemistry . It was not the chemistry faculty that made chemistry a requirement, although they certainly benefit from it. The students "weed" themselves out.

  • ginger says:

    I'm as intellectually curious, knowledge-hungry, as the next geek, but O-Chem is not how I would spend my time, given a choice. Lab was more fun than lecture, but not by that much, and again, I can think of more interesting ways to spend lab time.

  • NFQ says:

    As someone who's TAed that premed intro physics course before ... I'd say it is important, but not for the actual physical knowledge primarily. I think it is important as a "being able to process information and think rationally" class. As in -- here is a rule, here is a situation described; can you figure out what is important in this description and whether the rule applies / how to apply the rule? This is an important step in cognitive development, and if you can't make it, I don't know how we can expect you to be a good doctor. I know another TA from a different year that kept a list of "doctors to never go see" because of the students in their class who displayed a fundamental inability to use formal operational reasoning.

    In that particular program I was unaware of this course being thought of as a "weeder" course. Premeds didn't take it until their junior year or so, and physics or engineering majors took different intro courses. Just for clarification.

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