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  • Questioning the Premedical Paradigm: Enhancing Diversity in the Medical Profession a Century after the Flexner Report
  • Stephen Inrig, Ph.D.
Donald A. Barr . Questioning the Premedical Paradigm: Enhancing Diversity in the Medical Profession a Century after the Flexner Report. Baltimore, The Johns Hopkins University Press, 2010. 226 pp., illus., $40.

Unsuspecting readers might think that Donald Barr's Questioning the Premedical Paradigm critically evaluates the role premedical education plays in physician diversity. In reality, the book is a research protocol with an extended background and significance section. Barr's hypothesis? "[That] a restructured premedical curriculum will bring a more diverse pool of students into medical school without a decrement in the clinical or professional quality of physicians trained in this manner" (196). Barr is well positioned to answer this question: an associate professor of medicine and sociology at Stanford University, Barr coordinates both Stanford's Curriculum in Health Policy and their Program in Human Biology.

Premedical education has a long and relatively stable history in America, which Barr relates throughout the book. Prior to the emergence of modern biomedical science in the 1870s, medical schools had few acceptance criteria beyond a high-quality high school education and good moral character. Between 1873 and 1905, however, medicine underwent a scientific revolution. As medicine changed, educators like Daniel Coit Gilman and Charles Eliot became convinced "of the importance of science to medicine" and called for a new medical education model built on a foundation of science (Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education, Baltimore, Johns Hopkins University Press, 1996, 48). Premedical students should prepare for this science-based pedagogy by obtaining a strong grounding in chemistry, biology, and physics. Beginning in the 1870s, universities added physics, biology, and chemistry proficiency to its medical school admissions criteria. Then in 1893, Johns Hopkins formally established the prototypical premedical curriculum—requiring chemistry, physics, and physiology (43). In the ensuing years, medical bodies rallied around this premedical paradigm and, in 1905, the American Medical Association's newly created Council on Medical Education (CME) formally endorsed it. It was this premedical sequence that Flexner would champion in his 1910 medical education report. By the mid-1920s, most American medical schools expected it (158).

According to Barr, the 1920s were the years for the premedical paradigm's success. It was at this time that medical schools first received more applicants than spaces available. This selectivity emerged in part because AMA education reforms had shuttered numerous underperforming [End Page 668] schools. But the selectivity made school administrators wary about "wastage," particularly since as many as 25 percent of entering students failed their first year of medical school. To circumvent this wastage, schools began using scientific aptitude as the major mechanism by which to identify and avoid students most likely to fail. The first generation of MCAT emerged at this time, as schools combined it with GPA and premedical science aptitude as the main criteria of acceptance. Educators therefore began looking to the premedical curriculum—particularly preliminary science courses—to "weed out" those high-risk students, and this new pedagogical approach became the ruling paradigm for medical student selection in America. Thereafter, medical schools have primarily evaluated candidates based on their academic achievement in the basic sciences. Even after medical school failure rates no longer remained a prime concern, as occurred by the 1950s, this paradigm continued largely because physician-educators assumed that "increased performance in the premedical sciences would translate into increased clinical and professional quality among medical graduates" (175). Educators have sought to broaden the criteria by which admission committees accept students, Barr concedes, but performance in the premedical sciences has remained central to the process.

Barr would find none of this problematic if greater aptitude in the premedical sciences translated into increased clinical quality. Unfortunately, evidence amassed since the 1950s questions this assumption. Performance in premedical sciences does predict performance in the preclinical stages of medical education, but fails to predict professional performance and "has little if any association with ultimate performance as a physician" (180). Indeed, Barr notes, "overall verbal ability and a range of noncognitive strengths largely divorced from the premedical sciences are what best predict ultimate professional...

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