The Unspoken Harm in the (Pre)-Medical Experience: On History and Education

When the United States established its medical school system, we could have easily chosen to mimic Europe and create an alternative to the undergraduate degree for students who specifically wanted to become doctors. Instead, we created an idea of a “pre-medical student” who would finish a four-year bachelor’s degree in addition to pre-medical requirements before entering medical school. This would allow a unique, liberating approach in which we embrace the fruits of a liberal arts education while simultaneously preparing for professional school.

The pre-medical requirements include required coursework, volunteering, extracurriculars, shadowing experience, a good GPA & MCAT score, recommendation letters, and maybe a hobby or two. As the information of these requirements disseminates through the advisors, organizations, faculty, and students of college campuses, we perceive strict, superficial standards on what pre-medical students should do that are, actually, quite arbitrary and variable. By “arbitrary,” I mean, we aim for illusory goals and set standards to ensure we complete X, Y, and Z before we apply for medical school. We follow the footsteps of students above us, never stopping to question the effects this dogmatic approach to our education has on us. I will explore what effect pre-medical requirements have on our education, but, since there is very little literature and research done on the issues pre-medical students face, it would be more helpful for us to first understand the problems of education in medical school to see if they reflect among our behavior. Through a study of the history of medical education, we can understand how we, pre-medical students, can forward in the uncertain 21st century.

Before medical schools were firmly established in the States, soon-to-be doctors would serve menial duties under experienced physicians for a required term that would culminate in clinical activities. By the late 1800’s, the first medical schools, constructed to be intertwined with hospitals, gave a breath of education of the classics alongside clinical training. After completing a bachelor’s degree (including knowledge of philosophy, mathematics, and Latin), students completed a year of training before an apprenticeship and lectures. The overall structure of this seems similar to the way a pre-medical student must complete required coursework before entering medical school, residency, and securing a career.

The ominous, exciting turn of the 20th century into the darkness that was “Hand mit Ringen” (Hand with Rings), the first medical X-ray.

But how has the medical education changed over time? With advances in technology, science, and epistemology, medical education has always struggled to keep up with preparing students to approach the biggest problems of the future while retaining the human values that we cherish. Through progress and breakthrough in science, medical schools emphasized new technology and research-driven approaches in their education. This has forced medical schools to embrace confusing tendencies that attempt to balance the art and science of medicine with one another. realized we needed a professional ethos to guide us, and students and physicians would reflect on the changes that flew before their eyes. Maybe the course of history in the education of medicine guided through nostalgia. Even as far back as 1953, we find those who “lament the fact that the personal tie between teacher and pupil no longer plays so vital a part in medical education, and they would urge a return to the earlier mode of teaching.” But why stop there? In 1910, years after the establishment of a science-driven Medical School at Johns Hopkins, educator Abraham Flexner reminisced the thoughts of one student,

“Our teachers were men of fine character, devoted to the duties of their chairs; they inspired us to enthusiasm, interest in our studies, and hard work, and they imparted to us sound traditions of our profession; nor did they send us forth so utterly ignorant and unfitted for professional work as those born of the present greatly improved methods of training and opportunities for practical studies are sometimes wont to suppose.” 

Despite the progressively aggregating amounts of knowledge and its effects on human health, Flexner recognizes that the educators of the past were never as useless as the present students might think. Although Flexner does not suggest that medical students of his time were succumbing to an ominous, self-obsessed era of scientism and it would be ridiculous to assume that amazing advances in the sciences are driving students of medicine amok, there is still a balance of the sciences and humanities to be ascertained in order to completely realize Flexner’s vision of the American Medical Educaiton. For example, as the United States embraced the advancements of a science-driven era, some had hoped that the study of history of medicine would create a “counterbalance” to the “reductionist hubris” that plagued a physician’s knowledge in the science-dominated era.

I would occasionally browse Reddit on my phone as I sat in the crowded lecture hall during my Organic Chemistry II course this past semester. I would only look up to the notes on the projector when the professor had finished writing something new for me to copy into my notebook. Despite my distraction, I would try to review my notes over and over again until the professor would un-pause the streaming on his feature length film “Organic Chemistry II Notes.” We glazed at the information, soaking in anything and everything in the comfort that the professor would “only teach the things that would be on the test”, “this is how you solve the problem,” complete with practice exams and sample problems identical to those on the exam. I paid attention, though, as I believe understanding the puzzles and forces that governed chemical reactions was incredibly interesting. But, I lamented that the joy of learning science was reduced to a requirement that we were forced to suck-up.

I dropped that course later on in the semester.

Luciano Nezzo, 1856, A tooth-drawer concealing the dental key from the patient

Studies as recent as 2004 have examined the role that our modern economy has played on the medical education. “Habits of thoroughness, attentiveness to detail, questioning, and listening are difficult to instill when learning occurs in a clinical environment more strongly committed to patient throughput than to patient satisfaction. In addition, it is difficult to imagine how caring attitudes can be developed when medical education is done in a highly commercial atmosphere.” Necessities such as “questioning” and “thoroughness” are similar to the skills that I believe undergraduates need. I believe these issues of a “commercial atmosphere” among medical students parallel those that undergraduates face. Our business-like emphasis on fulfilling pre-medical’s requirements to please admissions officers causes issues of inhumane utilitarianism and dogmatic groupthink. 

Viewing the the undergraduate education as a means of gaining something (whether that fools’ gold is skill, experience, recommendation letters, grades, or even the ambiguous buzzword “professional experience”) moves us towards utilitarianism, a motive with harmful consequences. We would have a materialistic view that loses the humanistic value given by an education. This materialism is both marked by a lack of interest in wonder and awe of scientific phenomena (similar to Flexner’s emphasis on the combined role of humanism with science) and greedy reward-driven pre-medical requirements (similar to mindset of medical education in a modern economy). While it is ridiculous to say all pre-medical students engage in extracurriculars solely for the purpose of becoming a better medical school applicant, there is no doubt that many pre-medical students are motivated by the idea there is a practical benefit in what they do. This practicality-driven view of our education also gives rise to anxiety and envy. These characteristics of a utilitarian approach to our pre-medical career may cause issues if we are ever to fulfill Flexner’s dream of finding a human value in medicine.

Most importantly, if students are given a list of requirements that they must complete and achieve, then we will begin to see the fulfillment of those requirements as the purpose of our education. This, as I’ve explained with evidence from Harvard Medical School, should not be the case.  Similar to the reductionist attitudes that Flexner criticized over a century ago, we cannot simply view our activities as means of gaining a practical benefit. And it forces us to aim towards the “end goal” of gaining experience in these requirements before we have given enough thought to the meaning and challenges of those “goals. Learning how to ace an interview and approach ethical issues in medicine become means of preparing students for the future rather than methods of discovering the true purposes in those activities. By this, I mean that pre-medical students are often encouraged to approach the requirements directly without adequate and appropriate training or discussion of those subjects. 

All in all, we need more discourse among students. The lack of discussion, debate, and criticism about these issues demonstrate the groupthink that cause us to lose sight of what the value of an education should truly be. We mustn’t reject all the things pre-medical students have done nor devalue any benefit that we have already obtained from those activities. Rather, we should build upon what we’ve done and ask what the true meaning of a medical education should be.

As the old saying goes: Those who fail to learn from history will probably become doctors.

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