Rethinking Premedical Education

Rethinking Premedical Education

Rethinking Premedical Education
 
By Alexander Gelfand
 
Not long ago, Reuven Cohen was a health care analyst at SAC Capital, a hedge fund with $14 billion in assets. His job, which involved investing in biotech companies, was interesting, well remunerated -- and, ultimately, unsatisfying.
 
"I was attending conferences and spending my days talking to doctors about the various drugs and medical devices they used, but it was all purely intellectual," Cohen says. "There were no tangible results aside from making money. I wanted to leave a more positive, lasting result."
 
When Cohen became a father --he has a daughter, now five, and a son, two -- his desire to find a career that would both satisfy his intellectual curiosity and allow him to help others became more acute.

"It may sound hokey, but having children really did change my perspective on what was important to me," he says. "I wanted some integrity in what I was doing. There wasn't enough spin in the world to make it seem like I was helping anyone but myself."

Cohen's growing desire to make a difference eventually led him, as it has so many aspiring physicians, to the Postbaccalaureate Premedical Program in the School of General Studies.
 
Now in its 55th year, the program is the oldest and largest of its kind in the United States. Generations of graduates have used it to launch careers as doctors. (90 percent are admitted upon first application to medical school, while a small number choose instead to become dentists, veterinarians, and osteopaths.) And now more than ever -- as American medicine undergoes a sea-change, and experts debate the very nature of medical training -- those graduates are poised to make a powerful contribution to American health care, and to the communities they will one day serve.
 
The roots of the postbac premed program extend to the early 1900s, when Columbia first began offering premedical classes to students who were not enrolled as undergraduates. In 1955, the University established the Postbaccalaureate Premedical Program within General Studies for the express purpose of providing all of the prerequisites for admission to medical school.
 
Today, the 550 students enrolled in the program are fully integrated into the Columbia community. They take the same classes, with the same faculty, as the traditional undergraduates who sit alongside them; yet they themselves have a nontraditional approach to premedical studies. Many already hold degrees from the finest colleges and universities in the country, albeit without the scientific background required for medical school. And they often arrive fresh from substantial careers in other fields, from music and dance to journalism and finance, bringing with them considerable prior knowledge and life experience.
 
"I'm impressed, and I must confess humbled, by what they've done, never mind what they will do," says Andrew Sunshine, Director of the Postbaccalaureate Premedical Program. "Many of them have made significant sacrifices to be here. Many were doing well on Wall Street or in other professions, and in deciding to come here, their standard of living may plummet."
 
That pretty much sums up the experience of Reuven Cohen. Though he worked and saved for six years, the $60,000 Cohen estimates he will rack up in pre-housing costs by the time he completes the accelerated program -- cramming two years worth of coursework into just 18 months -- is nothing to laugh at, particularly when you live in Manhattan, study full-time, and have two small children at home. "It took me a year to build up the courage to leave Wall Street and return to school, and making my wife and kids sacrifice for me to go to this program gave me pause," he says. At the same time, there's nowhere he'd rather be, and nothing else he'd rather be doing.
 
Such stories are common among General Studies students, and postbac premed enrollees are no exception. "Many have really had to work in order to be able to undertake this degree," says Victoria Rosner, Coordinator of Academic Affairs for GS and Associate Dean of the Postbaccalaureate Premedical Program. "They understand it to be a transformative experience."
 
That was certainly the case for Judy Tanenbaum. When she enrolled back in 1982, classes were still held in the evenings. So Tanenbaum, who was ineligible for student loans but held an MS in child health from the University of Colorado Health Science Center, spent her days working as a physician's assistant in the Queens public schools, and her nights hitting the books. "Postbacs on the whole are deeply committed to their studies here because many are paying out of pocket," Sunshine says. "They're footing the bill, and with that goes a commitment to making it work."
 
Tanenbaum's day job didn't cover her expenses; but having decided to become a doctor, she was determined to complete "the best program possible." So her mother, who had already quit college to send Tanenbaum's father to law school, sacrificed yet again to send her daughter to Columbia.
 
Today, Tanenbaum is an assistant attending psychiatrist at New York Presbyterian Hospital and a clinical instructor in psychiatry at Weill-Cornell Medical College. And while the Postbac Program wasn't easy, Tanenbaum firmly believes that it gave her the preparation and support she needed to go from being a physician's assistant to being a physician. "It's incredibly competitive, it's time-consuming -- but so is becoming a doctor," Tanenbaum says. "There were hardships, but the professors and the head of the program were incredibly supportive. I credit them with helping launch my career."
 
In return, Tanenbaum recently gave $100,000 to establish an endowed scholarship in her mother's honor. By substantially adding to the $70,000 or so in scholarships that are currently available, Tanenbaum's gift will help expand access to the program, rendering it even more inclusive and diverse. And while that is in keeping with the overall philosophy of the University -- "diversity is a Columbia tradition," says Peter Awn, Dean of the School of General Studies, "and it brings a range of experience that is salutary" -- it is also extremely timely. The question of how to increase the number of underrepresented groups entering the medical profession has received considerable attention of late, in part because it has implications for both the types and the numbers of people who will be able to practice medicine in the 21st century -- issues that will only grow more pressing with time.
 
The Association of American Medical Colleges (AAMC), for example, predicts that the nation will face a shortage of 150,000 doctors by 2020 -- a shortage that will be spurred both by an aging population of Baby Boomers saddled with chronic diseases, and by the newly enacted federal health care law, which extends insurance coverage to an additional 32 million people. The most acute shortfall will occur among primary care physicians: the very same general practitioners, internists, and pediatricians to whom the new law grants even greater responsibility for coordinating patient care, and who are already underpaid in comparison with their specialist colleagues.
 
High educational costs, added responsibility, lower pay: this is not a recipe for increasing the supply of a much-needed class of professional, or of attracting already disadvantaged groups to its ranks. In the words of Dr. Howard Dean (former governor of Vermont, former chairman of the Democratic National Convention, and postbac premed class of '75), "unless doctors graduate without debt, they won't be able to go into primary care." Finding ways of expanding access to medical training while containing student debt won't entirely solve the problem, but it would certainly help.
 
Still, giving as many students as possible the opportunity to become highly trained caregivers is one thing. Determining how best to prepare them for their future roles is another. And that, too, has become a hot topic.
 
According to Donald Barr, an internist and sociologist at Stanford University who researches premedical education, the requirements for medical school admission have gone largely unchanged since 1905 -- this, despite revolutionary changes in the life sciences, and mounting evidence that many of the qualities and characteristics that we associate with good doctoring are neither taught nor assessed within the current system.
 
In an effort to address this problem, the AAMC recently published a report recommending that premedical programs move away from the prescribed diet of chemistry, biology, and physics, and toward a more flexible curriculum that focuses on inculcating the habits of research and analysis upon which physicians must increasingly rely throughout their careers. These "competencies," as the AAMC calls them, would hopefully equip future doctors to wrap their minds around everything from the latest breakthroughs in molecular biology to the ethical conundrums associated with genetic testing and end-of-life care.
 
Yet the question of how premedical and medical school curricula should be modernized is enormously complex, and unlikely to be answered any time soon -- especially when the pros and cons of any changes will have to be carefully weighed in light of many competing interests and concerns.
"Physics and calculus are not, in general, relevant to medicine," Dean says, by way of illustration. "On the other hand, I think that doctors should have a general understanding of how the world works, and your scientific training isn't complete without some understanding of physics."
 
Coming to a consensus won't be easy. But no matter where the process leads, Awn wants to make sure that Columbia plays a role in it. "I do not want to be simply a recipient of decisions coming from elsewhere," he says. "I want to be part of the conversation. I want the faculty and the community at Columbia to be part of the conversation." And the Postbaccalaureate Premedical Program may be uniquely suited to leading, never mind participating in, the emerging debate over the future of premedical education.
 
On the one hand, the program is justly famous for the rigor of its science curriculum. "The professors here go above and beyond anything I learned in my undergraduate classes," says Jonathan Friedman, who came to Columbia with a degree in psychology. "That's why I'm pretty much in the library 10 hours a day."
 
Yet the program is far more than an MCAT preparation mill; and the breadth of its offerings, coupled with the rich and varied backgrounds of its students, make it an ideal place to test assumptions and hypotheses about how best to prepare future health care providers.
 
For one thing, all students are required to complete 120 hours of work in a clinical or research setting. And this being New York City -- home to the largest municipal hospital system in the country, and to many of its leading teaching and specialty hospitals, as well -- the opportunities for top-flight placements are pretty much limitless. "One of the great things about the program is that a lot of different doctors and agencies around the city know about it," Friedman says. "So every week, the office gets flooded with hundreds of e-mails asking for students who might be available."
 
Friedman briefly worked in finance, but decided to pursue a career in medicine after volunteering at La Rabida Children's Hospital in Chicago and Riley Hospital for Children in Indianapolis. "I played with sick children, taught them how to read," he says. "I really enjoyed it -- the medical setting, working with kids. I decided it was time to become a doctor." He'd like to continue working with children, and given his background in psychology, pediatric neurology seems especially attractive. So this past year, he volunteered 30 hours a week in a cognitive neuropsychology lab here at Columbia. Cohen, meanwhile, did stem cell research with a cardiologist at Mount Sinai Hospital. Both say that they gained a perspective on the practice of medicine that they could not have gained through coursework alone.
 
Students also have the opportunity to participate in innovative colloquia like "Reading the Body," which presents narrative descriptions of the experiences of doctors and patients, and examines literary and cultural representations of illness and medicine. This kind of interdisciplinary work, otherwise known as "medical humanities," has become an important part of many premedical and medical programs. And while it might be tempting to regard it as simply icing on the cake, or as a less-than-critical complement to purely scientific training, that would be a mistake.
 
"There is evidence that those who are strongest in the humanities make the best doctors, so long as they're also strong in science," says Barr, who points out that there is a "significant correlation" between students' scores on the verbal reasoning portion of the MCAT, and their scores on the final stage ("Step III") of the United States Medical Licensing Exam.
 
This is not a new argument, though it is sometimes forgotten amidst the pressure to meet the narrow curricular requirements of medical school. As early as 1914, Abbott Lawrence Lowell, then president of Harvard University, made an impassioned and well-supported case for liberal education as the best foundation for a medical career. So when Awn contends that "a broad-based liberal education cannot but help improve your performance as a physician," he isn't just giving props to the many postbac premed students who come to the program with precisely such an education in hand. He is championing a philosophy that is as old as premedical training itself.
 
"Doctors are scientists, and they should be scientifically trained. But a liberal education is essential," says Dean, who graduated from Yale in 1971 with a BA in political science and worked as an investment banker before deciding to become a physician. (He continued to practice as an internist in Shelburne, Vermont, until becoming governor of the state in 1991.) "A doctor is not a mechanic. Doctors are often looked upon as leaders in their communities, and a wider education, where you have to know something about your culture and your history, is essential to be a leader."
 
But how do we as a society ensure that doctors receive not only the scientific training, but also the liberal education, that their jobs demand? How do we best prepare them to cope with the changing nature of scientific knowledge, and of American health care? How do we guarantee that we will have the number of doctors -- and the kinds of doctors -- that we will need in future? And how do we make certain that gifted and dedicated students can get premedical and medical training, regardless of financial need?
 
These are big, complex questions, and not ones to which definitive answers will be found anytime soon. But they are ones that the administration and faculty of the Postbaccalaureate Premedical Program are tackling head on, so that students like Cohen and Friedman will be prepared for whatever the future might hold -- just as Tanenbaum, and Dean, and thousands of others were before them. And they are also questions that postbac premed students may themselves be unusually well prepared to address.
 
"This is a time for creative and flexible outlooks," says Rosner. "And to the extent that postbac students have not had a straight trajectory to reach their premedical educations, I think that they will be well-equipped to participate in these debates, and in the changes to the health care system."
 
Cohen, for one, doesn't doubt for a moment his decision to pursue a career with meaning and purpose -- no matter how challenging it has been, or may continue to be.
 
"Now that I have invested the time and effort," he says, "I feel even more committed."