AM Rounds

Beyond the pages of Academic Medicine, journal of the AAMC


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Teaching Geriatric Medicine: It’s Personal

By: Benjamin A. Bensadon, EdM, PhD, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center

Geriatrics is a tough sell. As our article in the November issue illustrates, the multiple factors contributing to its ongoing unpopularity are psychological, economic, cultural, and pervasive. Though daunting, especially as our nation’s population continues to live longer, I believe there are many ways academic medicine can (and must) help.

The clearest cause for optimism may be the upcoming expansion of the MCAT in 2015, the importance of which cannot be overstated. Incorporating psychological and behavioral science content may result in more diverse medical school applicants, and hopefully lead institutions to follow suit with their curricula. Training in related areas such as communication, psychosocial aspects of medical illness, and the team-based biopsychosocial model, are particularly vital to elder care. Our attempts to infuse these concepts into our curriculum included several notable examples that struck a personal chord with our 4th-year medical students.

One method for acquainting students with geriatric care is exposure to “cool elders,” a program where we invite older community members to share their personal aging experiences (medical and other). By carefully selecting speakers students could identify with, and facilitating informal, honest, and non-threatening dialogue, we created a learning atmosphere where students observe “evidence” that dispels stereotypes related to both aging and psychosocial aspects of illness. For example, after one presentation by a husband and wife team of 90 year olds, I asked the couple “OK, so you have all these future physicians sitting here, they’ll be practicing in a few months, what makes a doctor a good doctor?”  The couple replied in unison, “TLC [tender loving care].” A few students smiled, others seemed surprised, all were engaged. The couple went on to add, “Oh you’ll get the diagnosis stuff, sure, that’s important, but we really need to know you care.”

In another example, a couple joked about their challenges with failing eyesight, reduced driving capability, and COPD self-management. The students were particularly moved when the man, diagnosed with emphysema 13 years earlier, said he had taught himself the harmonica in an attempt to improve his lung capacity. They also seemed disappointed when he reported most of his physicians were pessimistic about his prognosis. When he later adjusted his nasal cannula, pulled a harmonica out of his pocket, and played the students a song, their mouths dropped open in disbelief.

Opportunities to follow patients longitudinally, visit them in their homes, and experience intergenerational day care, all provided learners unique exposure to older patients’ challenges and capacity for resilience, a reality often distorted by aging-related bias and stigma. Perhaps nowhere was this more evident than in students’ reflection essays after attending community-based dementia support groups for patients and their family caregivers. Students frequently admitted personal misconceptions that the exposure corrected.

I was surprised that I, myself, had never considered caregiver health when now it seems like an obvious part of the care. To be honest, before attending, I wasn’t sure how the experience would help me in practice, but I left feeling that these women’s stories and struggles greatly impacted the way I view dementia.

They also differentiated between traditional learning from textbooks and experiential learning via the group, highlighting the latter’s unique capacity to affect students on both cognitive and affective levels.

Attending this group was absolutely eye-opening. In most of medical school, we focus on brain tissue change with dementia, but I didn’t realize my education was incomplete until I met these individuals and realized there are many aspects of patient care that go beyond just the patient.

Most students also reported being surprised and inspired and many ranked it their best learning experience in medical school.

Regardless of specialty, US demographics suggest that, for most graduating medical students, contact with older patients is inevitable. Fortunately, a care approach informed by negative, stereotypical views of aging is not, if we are willing to think outside the box and implement novel, evocative curricula to help shape students’ perceptions. In the US, geriatrics consistently ranks low in reimbursement but high in physician satisfaction, underscoring that geriatricians find their work gratifying and meaningful for different, often personal reasons. To be effective, then, our educational efforts must take a similarly personal approach to reaching our increasingly diverse students.


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Preparing to Take the MCAT: A Step-by-Step Guide

Editor’s Note: In honor of our collection of articles on the MCAT in the May issue, we’ve asked a few colleagues at the AAMC to compile a list of study tips and resources. The steps below do not apply directly to the MCAT2015 exam, but to MCAT preparation more generally. 

by Jen Page, director, and Abby Thomsen, senior specialist, MCAT Preparation Products, Association of American Medical Colleges

One of the requirements for attending almost any medical school in the United States and many in Canada is the MCAT Exam.  To help you prepare for this test, the AAMC offers several resources.

  1. You need to know what’s on the MCAT exam.  There are no required courses to take the exam, but you may learn the topics tested in typical introductory chemistry, biology and physics courses.  A complete listing of the content and cognitive skills tested is available for free download at: https://www.aamc.org/students/applying/mcat/preparing/Layout 1
  2. How long is the exam? How much does it cost? How often is it administered? The answers to these questions and more are in “The Official Guide to the MCAT® Exam.”  This introductory guidebook explains “everything MCAT.”  It includes an analysis of the exam content and each test section, lots of data about retesting and how scores figure in the admissions process. The book includes 146 sample questions with solutions and tips from the test developers.
  3. After learning what’s on the exam, take a timed practice test so you can see what the computer-based MCAT exam looks like and feels like.  Remember you should take a practice test after you’ve completed your introductory chemistry, biology, and physics courses.  The AAMC e-MCAT Practice Tests mirror the actual MCAT exam so you can practice completing the test timed in one, four-hour sitting like you would for the real exam. The AAMC offers a free exam to everyone and seven additional tests for purchase.  One strategy for using the free test is to establish a baseline score.  To do this, you can choose to “simulate the actual test” to find out how you would score if you tested today.
  4. Next, after establishing a baseline score, it may be helpful to plan out what you should study.   A new resource released in 2012 is The Official MCAT® Self-Assessment Package, which analyzes your strengths and weaknesses in MCAT content. Since this tool helps you figure out what content to study, you may want to use it after completing all of your coursework but early in your MCAT preparation.
  5. Once you’ve answered all 541 questions on the Self-Assessment Package, your analytic summary will show your performance in all areas so you’ll know what needs improvement.   As you study, you can take additional e-MCAT Practice Tests to monitor your progress by comparing timed test results to your baseline score.

Using all of the resources available to you, you can be more prepared and confident going in to the MCAT Exam. Good luck!

For more on theMCAT2015 exam, see the Preview Guide for the MCAT2015 Exam, as well as other resources on the MCAT’s website that are already available.  “The Official Guide to the MCAT2015 Exam” will be released in early 2014, and a sample test will be available in Fall 2014.


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Journal Club: May 2013

by Cynthia A. Searcy, Ph.D., director MCAT research, and Dana M. Dunleavy, Ph.D., manager, Admissions Research, Association of American Medical Colleges, Washington, DC

Overview of all changes to the MCAT

The Medical College Admission Test (MCAT) was introduced in 1928 as a way of assessing applicants’ readiness for medical school. The MCAT exam has undergone a major substantive review five times since 1928. Over the years, the exam has had a steady emphasis on natural sciences concepts and skills and verbal reasoning. However, the inclusion of other areas, such as quantitative reasoning, social sciences, and humanities, has varied.

Each version of the MCAT exam reflected the prevailing beliefs and evidence about the knowledge and skills important for success in medical school at that time. For example, the 1928 version responded to the Flexner Report’s call for foundational knowledge of chemistry, biology, and physics as a prerequisite to medical school; the 1962 version responded to the recognition that problem solving skills are required throughout medical school by emphasizing problem solving rather than memorization questions; and the 1991 version responded to calls for medical students to have strong communication skills with the addition of the Writing Sample.

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It All Comes Down to Validity: Thoughts on the MCAT

By Kimberly A. Swygert, PhD, senior psychometrician, National Board of Medical Examiners

A set of upcoming articles in Academic Medicine thoughtfully summarize the performance of the current MCAT and present a summary of the processes and decisions behind the development of the MCAT2015. While the articles cover an expansive range of topics, when viewed as a whole, they address the most important question one can ask about a test: how valid are the MCAT scores for the decision process of medical school admissions?  As validity expert Michael Kane often reminds us, validity is a property not only of a test but of the interpretations and uses of the test, and the MCAT research summarized in these articles is a way to “kick the tires” and show that MCAT scores work in the ways that test developers and users intend for them to work. Given the importance of the MCAT in determining not only who becomes a physician, but also the premedical curriculum designed for their education, the critical question of validity will require constant, focused research efforts by the Association of American Medical Colleges as the old MCAT gives way to the new.

As several of the articles note, the conceptualization of what makes a good physician has changed since the MCAT was last updated in 1991. Medical schools are seeking students who understand both the natural sciences and the social sciences underpinning the human side of the practice of medicine. Assessments of potential physicians may need to expand beyond academic competencies to include personal competencies such as resilience, reliability, and ethical responsibility. The applicant pools for medical school have changed greatly in the last three decades, becoming more diverse with respect to gender and ethnicity. The responsibility of the MCAT developers is to piece together the validity puzzle by finding the answers to specific questions that address these changes. Do MCAT scores continue to predict crucial academic outcomes? Do MCAT scores add value over and above the non-academic factors that are increasingly used in the admissions context? Does the MCAT work for all types of applicants?

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Medical School Admissions and the MCAT: A Modest Proposal

by David Muller, MD, professor, Departments of Medical Education and Medicine, dean, Medical Education, and chair, Department of Medical Education, Mount Sinai School of Medicine of New York University, New York, New York.

Kudos to MR5 for their tireless efforts to renew and improve the MCAT, and kudos to Academic Medicine for publishing a fascinating set of articles on the MCAT and its impact. While the published articles do address a wide range of topics related to the MCAT, Academic Medicine did not publish as wide a range of opinions about the risks and benefits of the exam. Such articles could have been solicited from groups as varied as Admissions Deans, Deans of Academic Health Centers, medical students, undergraduate students, and national pipeline programs for students who are underrepresented in medicine. Only one article, by Eskander et al, attempts to present a balanced critique of the MCAT in an effort to make recommendations about its universal adoption in Canada. The authors come to the conclusion that, despite its predictive utility, its ability to accurately quantify academic aptitude, knowledge base, and critical reasoning skills, and some reassurance that it does not disadvantage students from minority groups, in balance, the MCAT carries more risks than benefits.

The fatal flaws of the MCAT are for the most part not inherent to the exam but rather the way it has come to be used. It was never intended to dictate the scope and depth of an undergraduate education; it was never intended to be used as a global measure of academic excellence or suitability for medical school; it was never intended to be used as a marker of excellence that determines national medical school rankings; and it was never intended to disadvantage certain groups of students by spawning an industry of preparatory courses that require enormous investments of time and money that many can ill afford.

I want to offer a modest proposal. I believe that most of the flaws described above exist because of the way scores are reported for the MCAT. No one would defend the notion that the current method of reporting scores accurately represents a student’s abilities as a medical student, physician or physician-scientist; that a 40 on the MCAT is in any way better than a 35. The data from Dunleavy et al reveal that 90% of students who score a 30 will have Unimpeded Progress in medical school. With a score of 25, Unimpeded Progress still hovers around 80%. According to data from Monroe et al, students who have scored 33-35 on the MCAT have at least a 67% chance of being accepted to medical school, and as high as an 86% chance if their GPA is greater than 3.80. The chances of being accepted drop more precipitously for MCAT scores below 24.

Instead of the current method of reporting scores I would propose the following: anyone who scores above a 33 would fall into the ‘Exceeds Expectations’ category; anyone whose score falls between 24 and 33 ‘Meets Expectations’; and anyone whose score falls below 24 ‘Does Not Meet Expectations’. I did not arrive at my cutoffs using a sophisticated formula. I also acknowledge that setting such cutoffs will invariably disadvantage some students. But just imagine the consequences of publicly reporting scores in these broad categories. Students would no longer invest the time required to achieve the highest possible score. The prep course industry’s influence would shrink dramatically, leading to some leveling of the playing field for disadvantaged students. US News and World Report would no longer have a stranglehold on the way schools define quality, allowing all schools to finally embrace holistic review without fear of adversely affecting a ranking system that none of us believe in.

Changing the way MCAT scores are reported will begin to undo most of the harm, while preserving the benefits.

Editor’s Note: Dr. Muller is involved in Mount Sinai’s Humanities and Medicine Program (HuMed), which offers a non-traditional admissions track to undergraduates majoring in the humanities and social sciences. Notably, HuMed does not require its applicants to take the MCAT. Dr. Muller has published on the program in Academic Medicine and the New England Journal of Medicine.


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On the MCAT, and Getting In

Editor’s note: This month, AM Rounds is publishing a series of posts on the MCAT exam, in conjunction with Academic Medicine‘s collection in the May 2013 issue. To kick things off, Academic Medicine‘s Editor in Chief, Dr. David Sklar, shares his own memories of the MCAT and medical school admissions process, as well as his thoughts on the upcoming MCAT2015 exam. 

Like most practicing physicians, my memory of the application process to medical school has faded over the years, replaced with the memories of my patients, colleagues and the long nights in the hospital. After many years living in the skin of a doctor, I feel as if my life was always destined to involve medicine, and I cannot imagine another identity for myself. But there was a time when my course was not so clear, my destiny only a glimmer of a dream. No one in my family had ever attended medical school. Why should I think that I could? Doctors drove nice cars, lived in beautiful homes, went to country clubs, and played golf. I didn’t. The classes leading up to the MCAT weeded out many of my friends. Chemistry got my friend Charley. Organic got Jennifer and Tom. Physics finished off Tim, Felix and Charlene. Somehow Billy and I made it through and then there was the MCAT, and if we survived that, the interviews.

I remember the MCAT only in the vaguest of terms. I sometimes awaken from sleep in the middle of the night inside a dream in which I am pondering MCAT questions: a rolling pin was headed down an inclined plane at 3 degrees and there was an egg in the way that was a perfect sphere with a two-inch radius, but there was coefficient of friction that was slowing the rolling pin and I would need to figure out if the egg was going to crack. What sadist would construct such torture, these problems with tricks and booby-traps, equations and long sentences that made no sense? I remember the sweat and the smell of the room, the odor of animal fear. Each of us was a wildebeest on the plain, who had made it this far but now the lions would take some of us. Who would it be? It would happen suddenly and some of us would be gone; a letter in the mail would come with our score and we would know that all those years of premedical courses had been wasted, because of the MCAT.

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Articles from the May issue of Academic Medicine are now available online ahead of print. Check out our MCAT 2015 collection!

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For the first time since 1991, prospective medical students will sit down to a whole new MCAT in 2015. New published ahead-of-print articles in Academic Medicine examine characteristics and outcomes of the current exam and discuss the changes affecting the MCAT2015. In addition, other new articles address population and community health, teamwork, leadership training, and other important topics. Keep reading below for more details about this online-first content, which will be published in the May issue.

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