사회과학과 인문과학(SSH)을 전공한 학생이 의과대학 입학과정에서 소외되는가? Review and Contextualization (Acad Med, 2014)

사회과학과 인문과학(SSH)을 전공한 학생이 의과대학 입학과정에서 소외되는가? Review and Contextualization (Acad Med, 2014)

Is Social Sciences and Humanities (SSH) Premedical Education Marginalized in the Medical School Admission Process? A Review and Contextualization of the Literature 

Justin N. Hall, MSc, MPH, Nicole Woods, PhD, and Mark D. Hanson, MD, MEd, FRCPC

MCAT2015가 의과대학생에 대한 자연과학/행동 및 사회과학/인문학에 대한 전문가 의견을 반영한다.

These reports and the MCAT2015 reflect current expert opinion regarding the contributions of natural sciences, behavioral and social sciences, and the humanities to medical student selection.

미국의 premed 교육에 관한 오래된 논란이 있다. 그것은 SSH를 전공한 학생이 이공학을 전공한 학생만큼 의과대학에 준비된 상태인가, 그리고 의과대학에서의 수행능력은 동등한가에 대한 것이다. 1910년 플렉스너는 의과대학의 변화를 일으키면서, 의과대학 입학정책의 변화를 제안했다. 물리, 생물, 화학, 실험실 경험 등이 premed 교육과정의 기초가 되어야 하며, 이것을 잘 배우지 않은 학생은 지원자격이 되지 못한다고 했다. 플렉스너의 기풍은 미국과 캐나다 의과대학에 스며들었으며, 대부분은 과학과 수학을 선수과목으로 요구했다.

There is a long-standing debate regarding U.S. premedical education. That is, are students who majored in SSH disciplines as prepared as their science major counterparts, and do they perform as well in medical school? In his 1910 report, Flexner5 recommended sweeping changes to medical education including medical school admission policy. He described physics, biology, and chemistry, including laboratory experience, as foundational to the premedical curriculum, asserting that poor performance in these disciplines could identify unqualified applicants.6 Flexner’s ethos continues to permeate U.S. and Canadian medical schools, as most require some combination of prerequisite courses in science and mathematics.

플렉스너 보고서 100년을 맞아 학자들은 premed에서 인문학의 중요성을 다시 성찰해보았다. Riggs는 의과대학 입학시 인문학 선수과목이 없는 것을 이학 선수과목이 없는 것 만큼이나 의과대학 입학을 못하게 해야 한다고 주장했다. 1978년 Thomas는 의과대학 입학정책이 premed 교육과정에 미치는 안좋은 영향을 묘사하면서, premed 교육이 이학 과목에만 집중하면서, liberal arts 교육이 희생당하고 있다고 지적했다. 또한 premed교육은 문학의 고전을 다뤄야 하고, 이학과목의 심층 학습은 의과대학의 것으로 남겨두어야 한다고 했다. 또한 MCAT이 과학 과목에 초점이 맞춰져 있는 것을 완전히 없애든 초점을 바꾸든 하여 인문학, 역사학 등에 더 초점을 맞춰야 한다고 주장했다.

On the centenary of the Flexner report, scholars revisited the importance of humanities within premedical education.7,8 Riggs7 opined that the absence of humanities prerequisites should preclude medical school admission as does the absence of science prerequisites. In 1978, Thomas9 decried the detrimental impact of medical school admission policies on the premedical curriculum, criticizing premedical education’s emphasis on sciences at the expense of a liberal arts education. He suggested that premedical education should focus on the classics in literature, with in-depth study of sciences saved for medical school itself. He also suggested that the MCAT either be dropped entirely or changed to lessen the focus on sciences and increase the focus on literature, humanities, and history.

그러나 과학 과목을 선수과목으로 요구하는 것은 오늘날 의과대학 입학정책에서 강조되고 있다 AAMC의 가이드북을 보면 가장 흔히 요구되는 10개의 선수과목이 나와있는데, 8개는 과학 혹은 수학이고(물리, 유기화학, 무기화학), 2개만이 SSH이다(영어, 인문학). Muller와 Kase는 AAMC 자료에 따르면 2009년 의과대학에 입학한 학생 중 18% 이하만이 SSH 전공자이다

However, science prerequisites continue to be emphasized in medical school admission policies today. The AAMC Medical School Admission Requirements Guidebook identifies the 10 most common premedical course requirements,11 8 of which are science and mathematics courses (e.g., physics, organic and inorganic chemistry); only 2 are SSH courses (English and humanities). Muller and Kase12 report that, according to AAMC data, less than 18% of medical students matriculating in 2009 were SSH majors.

SSH premed 교육에 관한 오랜 논란을 보며 우리는 다음의 질문을 한다.

Given the long-standing debate about SSH premedical education, we pose the following question:

• Does SSH premedical education have a role in today’s medical school admission process?
• That is, should there be prerequisite SSH course requirements for all applicants?
• Should there be standards for how medical school admission committees consider and compare applicants with majors in SSH versus those with majors in the sciences?

Method

문헌 고찰

Literature review: Scope and criteria for inclusion

문헌 고찰

Literature review: Search terms and selection process

 

결과

Results

문헌 고찰

Part 1: Review of the literature

미국의 경험 An American experience.

The Humanities and Medicine Program (HuMed) at Mount Sinai School of Medicine (MSSM) 

The Humanities and Medicine Program (HuMed) at Mount Sinai School of Medicine (MSSM) offers the most compelling evidence for the advancement of SSH premedical education.12,14 HuMed is designed as

• SSH-특이적 입학 코스. 일부 2, 3학년 SSH전공자에게 의과대학 입학을 보장함.
  an SSH-specific admission stream, offering guaranteed medical school admission (contingent on successful completion of an undergraduate degree) to some second- and third-year students majoring in the humanities or social sciences.
• GPA 3.5 이상, 생물학과 일반화학에서 B학점 이상 받아야
  Students are required to maintain a minimum grade point average (GPA) of 3.5 in addition to earning a “B” grade in biology and general chemistry.
• 유기화학, 물리, Calculus, MCAT 불필요
  They are not required to take organic chemistry, physics, calculus, or the MCAT exam.12,14
• 고등학교,대학교 성적, 자기소개서 2가지, 추천서 3부, SAT점수, 2차례의 면접
  Other components of HuMed admission include high school and university transcripts, two personal essays, three letters of reference, SAT scores, and two interviews.12
• 일단 합격하면 학부 3학년을 마치고 8주간 임상경험, 의학 관련 주제(의료윤리, 의료정책) 세미나 참석, accelerated course 이수
  Once accepted, HuMed students must spend eight weeks after their third undergraduate year gaining clinical experience, attending seminars on medical topics such as bioethics and health policy, and taking an accelerated course on the “Principles of Organic Chemistry and Physics Related to Medicine.”12
• 의과대학 입학 전 여름학교 초청됨
  HuMed students are invited to a summer enrichment program before commencing medical school to familiarize themselves with clinical sciences teaching.12

대부분의 수행척도에서 동등함. NMBE Part II 정신과학 subtest에서 더 잘함.

Yens and Stimmel15 found that nonscience majors performed on par or better than their peers with science premedical education on the majority of performance measures and were significantly more likely to perform at the superior level of the National Board of Medical Examiners (NBME) Part II Psychiatry subtest.

비교 결과 

In the two HuMed studies included in our review,12,14

• 학업 no significant academic disadvantage was reported for HuMed students in terms of higher rates of serious academic difficulty in the first or second year of medical school12 or attrition rates.14
• nonschlarly leaves가 더 많음 HuMed students did, however, take significantly more nonscholarly leaves for personal, academic, or psychiatric reasons,12
• 일부 학업에 대한 헌신이 부족하여 잘 못함 with a subset of HuMed students not performing well academically because they lacked the commitment necessary for medical education.14
• 전임상 수행능력 약함 Preclerkship performance ratings (United States Medical Licensing Examination [USMLE] Step 1 plus first- and second-year basic science courses)14 were weak.
• 임상 수행능력 동등 Yet clerkship performance ratings (Comprehensive Clinical Assessment [COMPASS] II, clerkship performance)12 indicated basic equivalency, and those HuMed students with multiple clerkship honors often were those who had experienced USMLE Step 1 or basic science performance difficulties.14
• 정신과학, 일차의료 선호 HuMed students demonstrated enhanced performance outcomes and a predilection for psychiatry and primary care specialties.
• 정신과학 소아과학 임상실습 우월 HuMed students excelled in psychiatry12,14 and pediatric14 clerkships, and
• 일차의료, 정신과 전공 선택 they were more likely than other medical students to select primary care and psychiatry residencies.12
• 연구 비슷 HuMed and other medical students attained similar graduation research distinctions, but
• 연구 장학금 더 많이 수혜 HuMed students were significantly more likely than other students to be recipients of Doris Duke Clinical Research Fellowships and to undertake a research year.12

학업능력 Academic performance.

기본적 학업 수행 비슷

Generally, these studies reported basic equivalency in academic performance irrespective of premedical education. Outcomes compared included

• GPAs for each year of medical school,
• NBME and USMLE scores,
• delayed graduation and attrition rates,
• rates of academic difficulty, and
• average class ranking (see Table 1).

과학과목 이수 안해도 1학년 비슷하나, 생화학은 예외였음.

Caplan and colleagues22 found that the grades of first-year medical students who had not taken advanced science courses were equal to those of students with stronger premedical science backgrounds. The exception was biochemistry, where those with prior biochemistry experience had significantly higher grades. Koenig18 reported that although there was no significant difference between broadly prepared and science-focused medical students’ NBME Part I scores, science- focused students achieved higher mean scores for three science subtests, and broadly prepared students achieved higher mean scores for the behavioral sciences subtest.

유급률은 비슷하다고 나오는 연구도 다수이나, 일부 다른 결과를 보여주기도 함.

Although multiple studies reported similar attrition rates,14,16,27 other studies have reported contrasting findings.

임상능력 Clinical performance.

동등함

Multiple studies reported basic equivalency of clinical competence across medical students, residents, or physicians irrespective of premedical education.16,19,20,27,28,31,32 Outcomes compared included

• performance in clinical clerkships,
• first-year residency clinical performance ratings,
• humanism scores,
• patient-centered attitudes, and
• various clinical competencies (see Table 1).

HuMed 학생이 정신과, 소아과 실습에서 더 잘함

HuMed students’ clerkship competencies were basically equivalent with those of non-HuMed students except for HuMed students’ excellent performance in psychiatry and pediatric clerkships.12,14

입학과정의 상업화와 국제화 Commercialization of and globalization of admission processes.

의과대학 입시시장은 MCAT, MMI, 시험대비반 등이 있다. Tompkins는 플렉스너 이후 proprietary medical school이 사라졌으나, 시장은 시험 대비 과정에 관심을 가지고 있다. MCAT 준비는 수백만달러 짜리 사업이다 2010~2012에 61.3%~65.3%가 MCAT 준비 과정을 사용했다고 보고함. 또한 1/3 이상이 MCAT을 2차례 이상 봤다고 대답. ProFitHR 는 맞춤형 MMI를 제공.

This medical school admission marketplace comprises tools including the MCAT exam,39 the MMI,37,40 and test preparation courses.41–43 Tompkins43 notes that although proprietary medical schools may have disappeared post Flexner, business interests now focus on test preparation courses. MCAT preparation courses are one facet of this multi- million-dollar business. In 2011, 91,600 MCAT exams were completed.44 Between 2007 and 2009, MCAT computer-based practice test sales increased by almost 50%.41,45 Moreover, from 2010 to 2012, 61.3% to 65.3% of matriculating medical students reported using MCAT preparation courses, and more than one-third of medical school matriculants annually report taking the MCAT exam multiple times.46 The company ProFitHR has monetized the MMI, offering customizable MMI materials that can be applied across a range of tasks with applicants to medical, pharmacy, veterinary, and dental schools.37,40

미국 의과대학의 국제 협력이 사업이 늘고 있음.

U.S. medical schools are expanding48 with global collaborative ventures such as the

• Weill Cornell Medical College in Doha, Qatar;
• the DUKE-NUS Medical School and Research Center in Singapore; and
• the Medical School for International Health (Ben Gurion University), a joint venture with Columbia University Medical Center in Beer-Sheva, Israel— all of which employ the MCAT exam.50–52

고찰

Discussion and Conclusions

SSH 전공 학생의 학업/임상/연구 수행능력이 다른 학생들과 비슷하나 패턴이 조금 다르다. 예컨대 연구 탁월 수준은 비슷하나, SSH 학생이 임상연구에 대한 흥미를 더 보인다. 정신과나 일차의료 전공과에 대한 진로 선호가 높다.

The studies reviewed indicate that the academic, clinical, and research performance of medical students with SSH premedical education is equivalent to that of other medical students, but different patterns of competencies exist. For example, although research distinction is similar, increased clinical research interest is associated with SSH background.12 Enhanced performance outcomes in and career preferences for psychiatry and primary care specialties such as pediatrics are reported for students with SSH backgrounds.12,14 Notably, these career preferences may present a health human resourcing opportunity to address long- standing primary care and psychiatry physician shortages.33,34

MCAT2015에서 사회과학과 행동과학의 중요도를 높였지만, 충분하지 않아 보인다. 지원자들은 전략적으로 일부 SSH과목만 선택하여 들어도 MCAT을 잘 볼 수 있으며, 심리학이나 사회학 개론 정도 과목만 들을 것이고, SSH에 관한 폭넓은 독서나 학습을 할 것 같지 않다. 현재 MCAT은 임상수행능력을 예측한다(MMI처럼). MCAT시험과 MMI는 SSH전공 여부와 무관하게 의과대학생이 임상스킬의 잠재력을 가지고 있는지를 평가한다. 임상스킬은 입학과 관련된 중요한 성과지표 중 하나이며, 따라서 지속적으로 MCAT, MMI에 의존하면 premed교육에서 SSH의 설 자리가 점점 좁아질 것이다.

Although the MCAT2015 exam blueprinting process recognized the importance of the humanities and of social and behavioral sciences,4 we believe it does not go far enough, and applicants will behave strategically in their SSH course selections and readings to remain competitive for the MCAT2015 exam, likely narrowly selecting introductory psychology and sociology courses, rather than selecting and reading broadly within SSH as predicted.4 The current MCAT exam predicts clinical performance outcomes,41 as does the MMI.37 The MCAT exam and MMI enable selection of medical students with the potential for strong clinical skills, irrespective of SSH premedical education status. Because clinical skills are an important admission outcome, continued reliance on these tools may render SSH premedical education irrelevant.

MMI는 널리 사용되고 있으나 SSH를 premed에서 교육하는 것에 대한 논쟁은 아직 논란중

While the MMI is being implemented across the United States, Canada, and globally, SSH premedical education’s acceptance as legitimate premedical preparation continues to be debated.

더 나아가면 premed에서 SSH를 교육하는 것이 premed에서 과학과목을 강조하는 것을 '대체'하게 될 것 같지는 않다. 그러나 SSH교육의 장점을 더 잘 활용할 수 있는 세 가지 방법이 있다.

Going forward, it is unlikely that SSH premedical education will supplant the emphasis on science premedical education in the medical school admission process. However, three approaches could be explored to better incorporate the beneficial outcomes of SSH premedical education.

 

첫째, 일차의료의사 양성에 목적을 두는 의과대학은 적극적으로 SSH전공자나 SSH집중이수자를 선발할 수 있다.

First, medical schools with a mission to graduate primary care physicians could actively recruit prospective applicants with SSH majors or concentrations.

두 번째, SSH 입학을 HuMed와 같이 하나의 의과대학 입학 stream으로 도입하는 것이다. 이러한 HuMed식 접근법은 이렇게 들어온 학생이 동료들과 비슷하게 잘 한다는 지속적 경험을 통해서 문화의 변화를 촉진할 수 있다. 실제로 MSSM은 HuMed 프로그램을 확장하여 FlexMed 프로그램으로 만들고 있다. 비록 의과대학의 문화가 이들 SSH 출신 학생들에게 초기에 과학-관련 전임상 과목에 대한 추가적 지원을 해주는 쪽으로 바뀌어야 할테지만, 궁극적으로 이들은 동료보다 더 잘하거나 비슷하게 졸업한다.

A second approach would be adoption of an SSH admission stream as one component of a school’s overall admission

process, similar to MSSM’s successful approach with its HuMed Program. This HuMed approach may foster, as it has at MSSM,54,55 a cultural shift as faculty consistently experience the selection of medical students with graduation success on par with (or sometimes better than) their peers with premedical science education. Indeed, MSSM is transforming the HuMed program with its expanded FlexMed program.55 Although a school’s culture may have to shift to accommodate medical students with an SSH background who need early, additional support for science-based preclerkship courses, ultimately these students will excel and graduate alongside their peers.

SSH 특이적 입학 stream이 가지는 추가적 장점은 premed 교육의 비용을 낮추고 임상연구에 관심이 있는 학생을 더 모집하게 된다는 것이다. HuMed 모델에서 학생들은 MCAT을 보지 않아도 되므로 MCAT 준비에 들어가는 비용 부담이 사라진다. 이들은 연구 수월성 측면에서 비슷하나 Research Fellowship은 더 받았다. 이 fellowship 프로그램은 임상연구에 관심이 있는 학생을 대상으로 만들어진 것으로 - 기초과학이 아니라 - MD-PhD 프로그램의 보완complement이다.

SSH-specific admission streams like HuMed have additional benefits: decreased premedical educational costs and increased student interest in clinical research.12 The HuMed model12,14 does not require its applicants to take the MCAT, which eliminates the premedical education cost barrier of the MCAT exam and its associated preparation courses.41 HuMed students experience similar research distinction as their peers but significantly more often receive Doris Duke Clinical Research Fellowships.12 This fellowship program is specifically designed for medical students interested in clinical research, not basic science research, and serves as a complement for MD-PhD programs, which commonly attract students with basic science research interest.56

세 번째, 의과대학은 SSH 선수과목을 한두개, 혹은 매우 제한적으로 이수한 학생만 선발하는 것에서 더 넓혀 나가야 한다. 한두개의 SSH 선수과목만으로는 의도하는 교육 효과를 내기 어렵다. 단순히 SSH 과목을 수강했느냐 아닌가가 아니라, SSH 전공자나 SSH 집중이수만이 의도한 장점과 연관되어 있었다.

In a third approach, medical schools could revise their admission policies to include more than a single or limited number of SSH course prerequisites, as single or limited SSH course prerequisites policies may not have the intended educational outcomes. SSH premedical education with either an SSH major or course concentration, not simply SSH course counts, was associated with the beneficial outcomes noted in our review.

11 Association of American Medical Colleges. Chapter 2: Building a strong foundation: Your undergraduate years. In: Medical School Admission Requirements (MSAR), 2012–2013, United States and Canada. Washington, DC: Association of American Medical Colleges; 2012.

Table 1 Characteristics of the 20 Studies Included in a Review of the Literature on How Social Sciences and Humanities (SSH) Premedical Education Affected Performance During and/or After Medical School

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Acad Med. 2014 Jul;89(7):1075-86. doi: 10.1097/ACM.0000000000000284.

Is social sciences and humanities (SSH) premedical education marginalized in the medical school admissionprocess? A review and contextualization of the literature.

Hall JN1, Woods N, Hanson MD.

Author information

• 1Mr. Hall is a third-year medical student and Leadership Education and Development (LEAD) Program scholar, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Dr. Woods is a scientist, The Wilson Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. Dr. Hanson is associate dean, Admissions and Student Finances, Undergraduate Medical Education, and associate professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Abstract

PURPOSE:

To investigate the performance outcomes of medical students with social sciences and humanities (SSH) premedical education during and beyond medical school by reviewing the literature, and to contextualize this review within today's admission milieu.

METHOD:

From May to July 2012, the lead author searched the PubMed, MEDLINE, and PsycINFO databases, and reference lists of relevant articles, for research that compared premedical SSH education with premedical sciences education and its influence on performance during and/or after medical school. The authors extracted representative themes and relevant empirical findings. They contextualized their findings within today'sadmission milieu.

RESULTS:

A total of 1,548 citations were identified with 20 papers included in the review. SSH premedical education is predominately an American experience. For medical students with SSH background, equivalent academic, clinical, and research performance compared with medical students with a premedical science background is reported, yet different patterns of competencies exist. Post-medical-school equivalent or improved clinical performance is associated with an SSH background. Medical students with SSH backgrounds were more likely to select primary care or psychiatry careers. SSH major/course concentration, not SSH course counts, is important for admission decision making. The impact of today's admissionmilieu decreases the value of an SSH premedical education.

CONCLUSIONS:

Medical students with SSH premedical education perform on par with peers yet may possess different patterns of competencies, research, and career interests. However, SSH premedical education likely will not attain a significant role in medical school admission processes.

PMID:

 

24826852

 

[PubMed - indexed for MEDLINE] 

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