by Sanford J. Brown M.D.



You can get into medical scool COVER


MCAT and Its Place in the premedical Universe

For all the letters that I have received on the subject of grades I have received disproportionately few about the Medical College Admission Test (MCAT). Students tend to mention it parenthetically, e.g. "I plan to take the MCAT in the spring of my junior year," but I've had no really serious inquiries about the examination itself. In view of its extreme importance in the process of medical school admissions I've found this dearth of questions perplexing but not altogether surprising. Students, I've concluded, have generally underrated MCAT's significance and their ability to influence their test scores.


The MCAT is now required by all but three of the 127 medical schools in the United States (only the University of Rochester, Johns Hopkins and University of Missouri, Kansas City, do not require it). In contrast, only 13 medical schools require the baccalaureate degree. This implies that medical schools as a group value standardized test scores more than a four-year college education in their selection of applicants. Why might this be so, especially in light of ongoing criticism of the MCAT as being only a modest predictor of which students will succeed in medical school and valueless in predicting what kind of physicians they will become?


Picture the dilemma in the modern medical school's registrar's office. Every year four to six thousand applications arrive for one to two hundred freshman class places. How to sort them out? Clearly, there are two alternatives. Either you can have an admissions committee of 75-100 people so that each applicant will get personal attention, or you can feed GPAs, MCAT scores and lesser factors into a computer and review only those applicants who make a cutoff. The former approach happens at a minority of medical schools (the University of California-San Francisco being one). The latter method is more universal, for obvious reasons. Large admissions committees are unwieldy; smaller ones function more easily. Consensus is easier to reach and decisions among applicants can be made more quickly. But small committees do not have the time to read through thousands of applications. Hence, initial, non~personalized screening.

Now, if students are going to be judged initially by a computer there must be a way to turn their academic achievements into a score. A formula is devised, which will vary from school to school. Essentially, grades are weighed along with MCAT scores. Some college years may be weighed slightly more than others (junior over freshman) and perhaps some majors over others or some colleges over others, but this is minor compared with GPAs and MCATs. Standardized test scores give medical schools an impartial way to rate students from different schools, with different majors, of different races and sexes. For all their differences these premeds arrived at a testing center at the same time to sit through an all-day marathon exam that is designed

ultimately to lend an air of fairness to the decision of who does and who does not get into medical school.


I am no fan of the MCAT. I think it is basically unfair because it favors students who are good at taking tests (although it also gives the applicant from Podunk U. a better chance). It does not differentiate between good and excellent medical students and sheds no light on an applicant's suitability to be a physician. The only purpose it serves is to make the admission committee's job easier. And it is also in the proprietary interest of the American Association of Medical Colleges (AAMC) which owns and writes the MCAT, arid keeps the fees.


Rather than rant about MCAT's imperfections, it would be simpler to accept the reality that taking the MCAT, like death and taxes, is inevitable for anyone wanting to attend a U.S. medical school. The e~am has changed and will continue to change as more people demand that it become more relevant to the kinds of physicians we would like to produce. But, for now, it is important to do well enough on it to be invited to a personal interview, where an admissions committee member can see more of who you really are.


A question which arises from time to time is whether it is possible to prepare for the MCAT, particularly by taking an MCAT review course. I posed this question to Dr. Thomas L. Pearce, premedical advisor at the University of Virginia. This was his reply:


"Students must not expect that 'review' MCAT courses are really science review courses. Usually they are simple courses in examology; they try to teach students how to take a specific test on a specific date, namely the MCAT. This entails teaching test- taking techniques as much as, or more than, reviewing the required premedical sciences. Obviously topics covered in these 'review' courses include premedical subjects, but the emphasis is on taking the test, not reviewing comprehensively the material to be tested.


"I believe that students are just as well off, if not better off, by reviewing extensively and independently the subject matter on which they will be tested. All undergraduates I have taught these past 13 years have been experienced test takers, for they have been taking standardized tests for many years. I advise my students to take any 'review' courses they wish; I never advise them to rely completely on such courses. I urge them strongly to review all their class notes, every page of their introductory texts in biology, inorganic and organic chemistry and physics, and to buy the science review book written by James Flowers, available in paperback for $18.00. In addition I urge all of them to buy the MCAT Student Manual (2nd edition), which contains useful information about parameters of subjects on which they are to be tested as well as a complete MCAT, used several years ago. There are several books available which contain only practice MCATs; generally these are good to use as well, but only after the review studying has been done."


An interesting series of three articles about the MCAT appeared in the February 9, 1984, issue of the New England Journal of Medicine. It is, as far as I'm concerned, required reading for all premeds. The Journal received two unsolicited essays lambasting the MCAT. The third article was invited from the AAMC by the Journal to counterbalance an overwhelmingly one-sided view.


One essay, by Robert D. Powers, M.D., is particularly interesting. Dr. Powers, a young physician-in-training at the University of Virginia, had the opportunity to be the residents' liaison on that school's admissions committee (some schools even have upper- class medical students serving as members). Having last taken the MCAT in the spring of 1974 as a college junior, and recognizing that it had changed radically since then, Dr. Powers decided to take the exam again. After all, he was judging applicants on the basis of a test of which he, and all the other committee members, had little firsthand knowledge. So he sent in his application form, picture and filing fee and received back one admission ticket to the MCAT. The following abridged description of the exam is Dr. Powers':


The MCAT Revisited


"Exam day arrived, a rainy Saturday in early April. The first thing that struck me when I showed up at the biology building was that the students were taking this very seriously. It may be the only class of the year for which everyone is punctual. Although the information folder had advised us to bring two pencils, most examines came with five or six, just to be sure.

"To enter the room to take the test you must first pass a checkpoint where the picture you have sent with your application is compared with your face as well as with another picture identification card that you must have with you. You are then given a signature card that you sign at that point and again three more times during the day. All this security is a little unnerving. I wonder whether it's based on actual instances of cheating or just the paranoia that surrounds major events like this.


"The registration and identification process began at 8:00, but we did not begin to take test until 9:15. The first part ran until 11:00 a.m. It was the science-knowledge portion, consisting of 38 biology questions, 47 chemistry questions, and 44 physics questions. The biology questions were relatively straightforward and quite broad; someone who has taken a survey course and a cell-biology course could do pretty well on this section, although 38 seems like a very small number of questions to assess someone's knowledge of such a diverse field. The chemistry questions were tough, weighted toward thermodynamics, kinetics, and organic reactions, although there were a few simple equations and neutralization problems thrown in. At this point in the test I realized that I was being expected to remember details to a much greater extent than I had anticipated. I had trouble because I was unable to figure out the various valance states of the element manganese. Amazingly, it seemed that four or five questions revolved around knowledge of this particular fact. The physics questions equally demanded rote memory, testing recall of information rather than problem-solving ability. My principal handicap here was failure to remember the proper formulas for projectile problems. In numerous cases I was called on to calculate velocity, trajectory, or acceleration of various thrown and falling objects. In addition I was expected to know the effects of various types of lenses and mirrors on the size and orientation of the images they project. This was quite confusing and I had trouble finishing.


"The second morning session was a 90-minute test entitled 'science problems.' This test allegedly measures problem-solving ability rather than memory of facts, but I saw no difference between these and the science-knowledge problems. The questions were framed so as to include gratuitous references to health-care applications of chemistry and physics, but they were really just the same old projectile problems dressed up in medical outfits. Instead of dealing with cannonballs falling out of towers, we were asked to calculate trajectories of orthopedic traction weights falling off the ends of beds. Despite the attempts to make this section interesting and relevant, the test taker was doomed unless he or she could easily recall arcane formulas and laws of chemistry and physics. These questions easily filled the allotted time, and many in the room did not finish.


"My feeling about the entire morning portion of the test was that it measured recall of facts rather than cognitive function or reasoning ability. It was dry, dull and by and large totally unrelated to the practice of medicine. Unfortunately, it brought to mind the usual approach to the basic sciences in medical school: memorize for the exam, then forget; for it seems you rarely use the facts again.


"Lunch ran from 12:45 to 1:45 p.m.; if you were not back in your seat promptly, they voided your morning test and sent you home. At the break the crowd was subdued but relieved that the ordeal was half over. I overheard one student say that this would be his only attempt; if his scores were bad, he would rather not be a doctor than go through the test a second time.


"The afternoon session consisted of nearly three hours of reading and quantitative-skills testing. There were 67 questions in each category, for a total for the day of 327 problems. The reading section was much more pleasant than the morning science tests. It consisted of paragraphs dealing with both scientific and nonscientific subject matter. The questions related to this material, in most cases requiring that facts and interpretations be gleaned from the information presented. This forced the test taker to read critically and to be certain that concepts were adequately delineated and documented. Most of the questions were quite straightforward, drawing more on deductive skills, reasoning and problem-solving capacity than on knowledge of vocabulary or grammar. I found this section of the test to be much more relevant to the clinical years of medical school and the actual practice of medicine than any of the morning test sections.


"It was evident as the afternoon wore on that fatigue was a major concern for the test takers. This test is a marathon, and endurance certainly has a major role in the outcome for some people. Whether by design or by accident, the MCAT writers had saved the most thought-provoking questions until last. The quantitative section involved true problem solving, not the regurgitant performance required in the science-problem section. It was similar to the reading-skills test in that we were presented with information and then asked to draw conclusions and support or disallow statements made about the data. Instead of short paragraphs of written information, the material in this section was all graphic: pie charts, bar graphs, tables-virtually every method of presenting data was used in preparing the questions. Much of it was very similar to what one sees in the medical literature: an explanation of methods followed by data, then a set of conclusions that the reader is invited to agree or disagree with. Each problem contained the information needed to solve it; there was no need to recall dusty old formulas or definitions. This I also found very relevant to the sort of decision making that we are trying to educate our students to master; the great majority of the problems involved synthesis of information and deduction of justifiable conclusions.


"When the test was over it was after 5:00 p.m. The end of all the questioning was signaled by screams of celebration and the sound of champagne corks popping. Despite the fact that I had little at stake except pride, I was quite relieved. This was a long, hard test and not a lot of fun even without the pressure of having to do well. It announced that there would be an MCAT survivors' party; all were invited to drown their sorrows in beer.


"I set out to get an idea of how we should interpret applicants' MCAT scores. I wondered whether we used them in a reasonable way or wrongfully discriminated against those who did poorly and favored those who did well. After taking the test, I have these thoughts:


"The science portion is not of much value except to gauge the preparation of a student in some very narrow and quantitative aspects of chemistry and physics. In this respect, it does allow us to compare similar courses at different colleges.


"The science portion also tests memory to an extreme degree; the student who is a year or two away from science courses and does not prepare by memorizing formulas is doomed. This is very important to keep in mind when one is evaluating the applicant who has been out of college for a while. Beyond these uses I don't think the science and science-problem sections are worth much. However, the questions are like basic-science examination questions in medical school, and I would expect people who do well on the science portion of the MCAT to do well in the basic sciences if they are motivated enough to memorize lists of facts. As long as we continue to demand this of them in the first two years of medical school, this portion of the test will be a reasonable measure of their ability to succeed. The ability to do well on these sections may thus correlate with suitability to be a physician.


"The afternoon sessions are quite the opposite. If the morning sections correspond to the basic sciences, the skills tested in the afternoon relate to the clinical years of medical school and the actual practice of medicine. Information is available and accessible, but the data must be analyzed and decisions made individually. From this point on, I will regard performance on the reading and quantitative sections much more highly than I have in the past.


"In comparing this examination with the one I took in college, I have had most of my suspicions confirmed. I was sorry to see the general information section eliminated during the MCAT revision in the late 1970's, and I am even sorrier that it has not been restored in any form as yet. Despite the strengths of the afternoon section, it is still possible to do very well on this entire examination without any knowledge of music, art, philosophy, religion, literature, history, current events, gardening, hunting, fishing, or athletics. Although familiarity with any or all of these subjects is not essential to being a competent physician, I think that most patients would agree that a doctor who can relate to their interests and problems outside the office is better able to care for them than one who cannot. It is unfortunate that the call for more humanism in medicine has been answered by the almost complete elimination of the humanities from the only test to which all medical-school applicants have a common exposure."


Dr. Powers goes on to lament "the absence of the non-academic side of life" from the MCAT and states that letters of reference from premedical advisors have, along with everything else, become inflated with praise and superlatives, rendering them at times unreliable. The personal interview may leave lingering

doubts as to which people may be good technicians but poor physicians. Dr. Powers ends with a plea to the AAMC to devise a more~ well-rounded examination that does more than measure proficiency in science. In fact, the spring 1985 and 1986 MCAT will feature a forty-five minute essay subtest in an attempt to gather some data about the communication and reasoning skills of applicants. This inclusion is being undertaken on a pilot basis to determine if it provides information useful in admissions decisions. However, a total exam overhaul is still a long way off. In the meantime, don't hold your breath. Get crackin' for the MCATs!




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