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Monday, 16 April 2012

Making Doctors more Ethical

The Association of American Medical Colleges (AAMC) has redesigned its Medical College Admission Test (MCAT) for the first time since 1991. For premeds, the MCAT is like the pearly gates - they have to pass through it to get to the promised land of medical school. It's more than 50 years since I took the MCAT, but as I wrote this paragraph I felt my pulse going up. Our innards don't forget major stressors from the past!

Starting in 2015, the MCAT will add a section on psychology and sociology and another on critical analysis, to the sections on the hard sciences and mathematics. The AAMC wants to send the message to premeds and colleges that medicine requires more than mastery of scientific knowledge. And they're right - taking good care of patients requires understanding the patient's psychology and social context, application of critical analysis to diagnosis and treatment planning, and the interpersonal skills for developing trusting relationships.

The MCAT section on psychology and sociology will be organized around five basic truths about human nature and society that the designers of the test call "foundational concepts":
  • Biological, psychological, and socio-cultural factors influence the ways that individuals perceive, think about, and react to the world.
  • Biological, psychological, and socio-cultural factors influence behavior and behavior change
  • Psychological, socio-cultural, and biological factors influence the way we think about ourselves and others.
  • Cultural and social differences influence well-being.
  • Social stratification and access to resources influence well-being.
The draft version of the new MCAT probes these basic truths with challenging questions. Some of them were tough to answer. I didn't get a perfect score.
At a welcoming event for first year Harvard Medical students in 1960, a distinguished scientist on the faculty asked me what I'd majored in at college. I told him - a combined major in philosophy and psychology. He responded - "philosophy and psychology - what are you doing in medical school?" 

The AAMC doesn't want that kind of "greeting" to happen in the future.

The AAMC is entirely right to extend the scope of what the MCAT examines. The new standards, however, are just a drop in the bucket for changing the culture of medicine. Doing well in psychology and sociology courses won't be hard for smart undergraduates. Course work matters,  but character can be refractory to book learning.

In a freshman philosophy course in college, the instructor asked "how many of you can refute Plato's argument for XYZ?" None of us raised our hand. "So am I right that you have all decided to change your lives in accord with XYZ?" Again, none of us raised our hand.

His point - the dissociation between what was on the page and what was in our hearts, was clear. In a similar vein, in the anatomy lab during my first year of medical school the instructor came to my table and asked our group about the course and branches of the femoral nerve (the major nerve going to the leg). Studious book learners that we were, we looked at the ceiling and tried to recall what we'd read in the anatomy text. The instructor suggested - "wouldn't it be better to look at the dissection you've just done?"

What premeds learn in social science courses is important, but what they learn from personal relationships, their jobs, teams, and volunteer activities has a deeper influence. I love leading a section of the first year Harvard Medical "Professionalism and Medical Ethics" course, but I think of it as trying to impart a framework that - with good luck and good mentoring - the students will be able to apply in their future clinical work. Albert Schweitzer taught that "Example is not the main thing in influencing others. It is the only thing." The example of what the AAMC is saying in its redesign of the MCAT is probably as important as what future students will learn in Psychology and Sociology 101!


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