July 30, 2012 (New Orleans, Louisiana) — There are major challenges to increasing underrepresented minorities in medicine, among them the new Medical College Admissions Test (MCAT) that is scheduled to be introduced in 2015, according to Brenda E. Armstrong, MD, dean of admissions at the Duke University School of Medicine, in Durham, North Carolina.
"The new MCAT is a monster exam," said Dr. Armstrong in a keynote address here at the National Medical Association 2012 Annual Convention and Scientific Assembly. Dr. Armstrong is also professor of pediatrics and pediatric cardiovascular medicine at Duke.
The test, she noted, will not only ask far more about the field of natural sciences, it will also ask about aspects of psychosocial health, the humanities, and other nonmedical issues.
New Test Items
The recommendations of the M5 Committee of the Association of American Medical Colleges (AAMC) describe 4 test sections: biological and biochemical foundations of living systems; chemical and physical foundations of biological systems; psychological, social, and biological foundations of behavior; and critical analysis and reasoning skills.
Dr. Armstrong noted that the natural sciences sections of the exam will test not only introductory biology, but also organic and inorganic chemistry and concepts of physics; highly rated biochemistry concepts at the level taught in most first-semester biochemistry courses; cellular/molecular biology topics at the level taught in most introductory biology sequences; and basic research methods and statistical concepts described by many baccalaureate faculty as important to success in an introductory science course.
The test will also ask applicants to use their knowledge of natural science concepts to demonstrate skill in scientific inquiry and reasoning, research methods, and statistics.
The section on critical analysis and reasoning skills will test examinees' reasoning by asking them to critically analyze information provided by passages from a wide range of social and behavioral sciences and humanities. It will not require specific knowledge in these disciplines but, by calling them out, might prompt students to read broadly as they prepare for medical school. The test will include passages about ethics and philosophy, cross-cultural studies, and population health, she said.
Questions Remain Unanswered
As the revision moves forward, Dr. Armstrong said she "suspects there will be changes."
"We don't know if the MCAT, as it is currently conceptualized and formatted, is the best functional test of aptitude and skill-set development," she explained.
She asked whether the application process should include a dynamic test of problem-solving and critical thinking aptitude, and whether it should test for bioinformatics exposure and aptitude. "In other words, should we change the interview process?" she continued.
Dr. Armstrong also questioned whether it is realistic to think that standardization of course content and competencies can be achieved, "given local politics within university departments" and, if not, whether there is "an overarching rubric that can be developed for all schools to assess competencies."
She touched on a core issue related to the underrepresentation of minorities — to audience applause — asking whether decisions can be made about a student's ability to handle medical school "without taking into account the effect of the lump sum of substandard education going way back."
New MCAT Is a Positive Change
However, Marc A. Nivet, EdD, chief diversity officer for the AAMC, defended the new MCAT to Medscape Medical News.
"The reason we revised the MCAT is to ensure that the physicians of the future have the right understanding of the broad social determinants of health. Yes, the MCAT is a test of one's capacity to be a successful medical student, but with the revision, we are saying that...the courses you take before you come to medicine" are really important, he said.
Dr. Nivet explained that the AAMC wants to encourage a broader understanding of the social and behavioral determinants of health, balanced with an understanding of science. "That's a big push in our changing the MCAT," he said.
"What you are hearing from Dr. Armstrong is that change is hard. The road is not going to be easy the first few years, but we are allowing ourselves the flexibility to adapt," he said.
"We will be very critical of ourselves so that the MCAT remains as fair as a standardized exam can be," he noted.
He emphasized that the AAMC has advocated for diversity for 40 years, "and we only want to accelerate this.... We do not want to disenfranchise any particular groups of students by socioeconomic status, race, or ethnicity," he said.
To meet this aim, the AAMC will meticulously assess the value of these revisions, "question by question," and will be proactive in areas where problems are expected.
The association suspects that the greatest "struggle" with the new MCAT will come from students in "lower-resource institutions," which are historically the colleges and universities serving black and Hispanic students, and "liberal arts colleges without large endowments," he said. These institutions will receive "outreach and support" from the AAMC, which aims to quell potential problems before they occur, he said. "We care about making sure we are not unfairly harming any students in this process."
Threats to Diversity
Dr. Armstrong expressed her concerns in the context of a larger discussion about obstacles to diversity in medical schools. These challenges include the effect of the Scientific and Behavioral and Social Sciences Foundations for Future Physicians on premed preparations, the looming Fisher vs the University of Texas Supreme Court test of affirmative action (scheduled to be heard in the fall), the rising cost of a medical education, and the impact of the US News & World Report "rankings" on the strength of institutional priority for and interest in creating diverse classes, she said.
Her overriding suggestion to help face and overcome these and other obstacles is "mentoring," and doing so on multiple levels, from elementary school to college.
"I want to sound an alarm. We are in deep trouble, and it is worse than it was years ago," Dr. Armstrong told the mostly black audience. "The only way we can turn this around is to mentor personally and professionally."
Dr. Armstrong and Dr. Nivet have disclosed no relevant financial relationships.
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