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The Premed Machine

On a cool spring evening, with mid-terms looming, a Penn premed talks about the kid they call "the Machine":

"Unbelievable. He sits down, opens the chem book and doesn't move for 12 hours. He's great, and you know why he's great? Because he forgot how to be bored. The kid does not get bored. He doesn't try to understand it. He just puts what's in the book in his brain...3.98 GPA. That means one B. Seventy-eight on the MCATS [Medical College Aptitude Test]. Seventy-eight MCATS is not human."

No one goes one-on-one with the Machine. At five feet, three inches and perhaps 100 pounds, he's the Dr. J of the premed big leagues.

It's a game that can be played different ways. At Stanford several years ago, premeds were blamed for staging a bomb threat to buy more time to study for a chemistry exam. According to the American Association of Medical Colleges, hundreds of wildly adulatory letters of recommendation are forged every year. Occasionally, says an AAMC executive, students fake professors' letters maligning classmates with whom they're competing. Among premeds, says a chemistry professor at the University of Pennsylvania, you will find some "true evil."

"It's a feeling like when you look around a big lecture hall," says Dan Guttmann, a senior at Penn, "and you know all these people because they're in all your premed classes, and it's kill or be killed."

Of the prestigious career tracks that entice the

Paul M. Barrett is an editor of The Washington Monthly. Richard Ehrle assisted with research for this article.

THE WASHINGTON MONTHLY/MAY 1985

By Paul M. Barrett

brightest students on the best campuses, medicine has the greatest impact in shaping undergraduates' lives. Grades make the man in premeds' eyes, because that's what they perceive the medical schools are looking for. Caught up in fierce competition for class rank, many students lose sight of the world beyond the library and lecture hall. College becomes a survival test, often dull and demeaning. Worse, the premed culture takes standard-issue high school overachievers and injects them with traits we increasingly complain about in our physicians: narrow-mindedness, cynicism, dishonesty. Young people who distrust their classmates, who cheat as if by second nature, who feel the world owes them a lifelong debt of gratitude-these are tomorrow's doctors.

Someday, the Machine will have an M.D. But you won't be able to get in to see him for months.

Ferocious geeks

The University of Pennsylvania doesn't “have your Widener Library [Harvard] or your classics [Yale], but we do what we do well-and that's pre-professional," says Frederick Brutcher, who teaches organic chemistry at Penn. The word gets out to students, who arrive at the sprawling campus in West Philadelphia like pilgrims at the Holy Land, the anticipation of salvation burning in their eyes. Officials at the university estimate that out of a freshman class of 2,000, 900 students consider themselves premed. Two-and-a-half years later, the 300 or so who have survived the grades gauntlet submit medical school applications. Penn is the perfect place to hear premeds

41

(CH,),CBr + H2O → (CH,),COH + (CH,),C=CH2 + HBr

tell their own stories.

"When I arrived, I lived in Ware College House, which is premeds exclusively," says Steve Kolenik. "It's full of geeky kids who look at each other and get more geeky. By the end of freshman year, I was a complete wreck. I went home for vacation, and I had lost 15 pounds.... It just got insane with everyone studying the same things at the same time. You look around and you start to be unsure of your abilities. Sophomore year, I was more confident. I knew how to get the As, but with people around you studying like crazy, you just keep at it. It becomes a habit." Kolenik, a senior majoring in biology, got into med school; he's a success.

Scott Epstein had a rougher time. "It's the atmosphere that did it to me," he says. "You don't know what it's like when you see these huge classes. Sophomore year it really hit." Epstein speaks softly; at several points, his voice cracks with emotion. "Everyone is fighting everyone else. I guess my grades went because of that, even though I was trying to beat the mean like everybody else....I tensed up. I got two Cs in bio. I had two terrible professors; they were weeding us out as if they were working for the medical school or something. They seemed to enjoy failing people, giving Cs and Ds. You get the feeling that no one is on your side."

Epstein, who recovered from his sophomore slump to put together a respectable academic record, hasn't gotten into any of the 12 medical schools to which he applied, although he's on a few waiting lists. He plans to attend a college of osteopathy, a system of quasi-medical physical manipulation based on a theory that diseases are due chiefly to loss of "structural integrity." "I guess I'm getting paid back for not doing well my sophomore year," says Epstein, "but I have friends who haven't gotten in anywhere. At least I'm into a place."

Penn isn't the only school infected by the premed syndrome. C. H. Haagen, a Wesleyan University researcher, surveyed the premed scene at several small liberal arts colleges, including Wesleyan, Amherst, and Swarthmore. Haagen found that premeds feel greater stress than students interested in other occupations and are more likely to alter course selections and extracurricular activity to improve their shot at med school admission. Fifty-three percent of the 1,065 students interviewed felt many of their peers disliked them, while 24 percent believed their instructors didn't like them. Forty-five percent of

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students who abandoned plans to become a doctor did so because they didn't want to join a profession filled with such grimly ambitious people.

Despite the evidence, some people in medical education are skeptical about the extent of the premed problem. "There are kernels of truth, individual cases," says Dr. Gerald S. Foster, director of admissions at Harvard Medical School, "but the [premedical] thing is often blown out of proportion....I see scores and scores of marvelous students." Steve Kolenik, who's on the waiting list at Harvard and would like to hear from Dr. Foster, is one such marvelous student. He's done advanced lab research and is fascinated by heart surgery. He chose medicine because he wants to do something "that helps make people feel better." But as Kolenik himself admits, even for the marvelous ones, the premed experience fosters extreme behavior that may permanently affect their attitudes toward medicine.

Killer weeds

Premeds know the numbers with icy precision: each year 35,000 students apply nationally, and fewer than half get in. So premeds play it safe, generally majoring in science (three-quarters of those admitted concentrate on science). Some are genuinely interested in biology and chemistry; but many hide in those subjects, insulating themselves from anything not specifically required of them by medical school admissions committees. Steve Kolenik describes why a premed would be afraid to major in philosophy and work in chemistry on the side: "You think you'll get behind before you even start, that the science majors will have a head start." In fact, the acceptance rate of humanities and social science majors is as high as or slightly higher than that of science majors. But the raw numbers can appear discouraging: in 1983, 212 English majors and 149 history majors were accepted nationally, compared to 5,948 in biology.

Medical schools traditionally pay special attention to applicants' grades in certain difficult science courses-the "weeders." As a result, premeds take a lot of nonscience "guts"-courses known to be easy As-because they say they need all their energy to survive the weeders. And of all the weeders, organic chemistry is the most merciless. Uniformly required by medical schools, organic is the GPA-crunching monster that haunts premeds on every college campus. Many students consider a C in organic fatal to medical

-> (CH,),C++ Br (CH,),C++ H2O −> (CH,),COH + H* (CH,),C*

"There are professors who are anti-premed. If they
can kill off a few quietly, they sort of enjoy it.

aspirations. It's "the course of broken dreams," says Frederick Brutcher of the Penn chemistry department.

Organic chemistry is the study of how elements fit together and break apart in chemical reactions involving carbon. The course requires rote memorization of a complex algebra of chemical equations. A cornerstone of the chemist's profession, organic came to prominence in the 1920s and '30s, when new industrial applications were discovered for chemistry and universities expanded their faculties in the field. Physicians must have some grounding in general chemistry to understand topics such as biochemistry and pharmacology. But organic chemistry, with its detailed treatment of carbon bonding, has almost no relevance to medical practice. This is an open secret, unknown, it seems, only to the premeds who take the course. "I've asked many [physicians], 'Do you use organic chemistry in your day-to-day work?'" says Brutcher. "No, they don't....In my humble opinion, it's used more as a screening course-that's all."

Brutcher and his academic colleagues see a transcendent beauty in the innumerable patterns of carbon bonds, but little of that wonder filters down to their students. Brutcher readily concedes the point: "I say to [students], 'I know you come to get two things: a high grade and a good recommendation letter.'" He acknowledges the frustration a research scientist feels teaching students who don't respect his field and, to make matters worse, will probably one day make a lot more money than he does. "Every scientist is looking for his wunderkind,” says Brutcher. "He wants the next Einstein....The premed has no meaning in my field." Although he is himself a genial man, popular with his pupils, Brutcher confirms the students' perception that some professors have it in for premeds. "There are organic chemists-let me be blunt-who are anti-premed," Brutcher says. "There's a percentage who do enjoy the power, and if they can kill a few quietly" Brutcher's voice drops to a whisper-"in my humble opinion, they sort of enjoy it."

Not surprisingly, a class like organic brings out the worst in students. Timmy Sullivan, a fourthyear student at the Tufts University School of Medicine, recalls that things got ugliest during organic lab sessions. Crucial equipment disappeared in the dark of night, Sullivan says. “One guy had worked on an experiment for five weeks, and then one morning, it was gone.". Brutcher says out-and-out sabotage is rare, but psychological warfare common: "The girl comes down to the front of the class; she's crying. She says, 'Dr. Brutcher, I'm sitting in the back of the class and I didn't hear what you said. I turned to this guy, and I told him, "I missed what Doc said." He said to me, “I will not tell you. You're competing with me for a seat in medical school."' This sort of thing happens, oh yes."

The anecdotal evidence, if anything, probably understates the level of anxiety and twisted behavior. Cheating is a good case in point. Professors concede that it occurs; Brutcher says that the most common technique is the surreptitious scrawling of key information on lecture hall chairs so that it is available for easy reference during exams. Students describe other, more daring infractions, including circulation of test questions obtained illegally. But the statistics tell an even grimmer tale. A recent study of 400 medical students by doctors at two Chicago medical schools revealed that 88 percent of the subjects had cheated at least once while they were premeds. The researchers found widespread cynicism among their subjects, as demonstrated by frequent agreement with statements such as, "People have to cheat in this 'dog-eat-dog' world."

Walking wounded

Four years of being a premed takes its toll. Again, take cheating as an example. The Chicago study demonstrated that although the frequency of student cheating dropped in medical school, the majority of students continued to cheat. "The most disturbing finding," the researchers concluded, was that "there was a continuum from

-> (CH,),C-CH2+ H+

H2C-CH2+ 3CO + 2H2O -> CH,-CH2

cheating in college, to cheating in medical school in didactic areas, to cheating in clerkships in patient care....Cheating in medical school may be a predictor of cheating in medical practice." From crib notes in organic chemistry to Medicaid fraud and fudged results of medical research: the connection may be there.

More subtle links exist between the premed regimen and bad medical care. As a society, we're growing increasingly dissatisfied with our doctors. A study described in a recent Institute of Medicine report on medical education found that 64 percent of a large sample of families were unhappy with their doctor-patient relationships. One-third to one-half of the families had changed doctors because of dissatisfaction over the physicians' personal qualities. While premeds are learning to cheat, they're also becoming narrow, driven people, uncomfortable dealing with others. Dr. Carole Horn, admissions director at the George Washington University Medical Center, says that undergraduates put through the premed mill have difficulty providing patients with the "trusting, caring feeling people like to get from a doctor."

In a 1983 report on problems with medical education, Derek C. Bok, president of Harvard University, also stressed that future doctors are not adequately prepared to deal with the human elements of medical practice. Bok noted that many patients who visit primary-care physicians have no physical ailment. Yet research indicates that many doctors overlook significant emotional and cognitive disorders. Bok added that "through lack of empathy and concern," physicians may "fail to detect these psychological and social considerations [and]... misperceive the nature of the case before them and resort to unnecessary surgery, overuse of drugs, and needless diagnostic tests."

Recent developments in medicine make it only more imperative that students entering medical school understand the world from a humane, as well as a technical, perspective. Premeds receive little encouragement to begin thinking about topics such as the use of extraordinary lifesustaining techniques, the allocation of scarce medical resources, or the use of prenatal diagnoses in making abortion decisions.

The emphasis on memorizing in premedical education not only can hinder premeds in dealing with human and ethical problems, but it may also hurt them as scientific investigators. "The kind of knowledge they pump into you doesn't

stay in your brain very long," explains Harry Moscovitz, a second-year student at Mt. Sinai School of Medicine. A recent study at Case Western Reserve University found that secondyear medical students forget 90 percent of the factual items they learn in lecture courses by the time they graduate two years later. Acknowledging such evidence, several major medical schools are experimenting with new curricula that stress problem-solving in a small-group setting, rather than memorizing information presented in large lecture classes. Premeds, however, are still put through courses designed specifically to test their ability to retain raw fact.

A final result of the premed experience is a strong sense of resentment on the part of some undergraduates. Many Penn premeds say that they realize they are not well liked as a group by nonscience students and that they miss out on the more pleasurable aspects of college life: namely, exploring new intellectual areas and socializing in a casual atmosphere. What you hear in this grumbling is the faint echo of a chord that grows stronger through the four grueling years of medical school and the 100-hour weeks of clinical internship. It's the common justification for physicians' tendency to be preoccupied with material rewards: I've sacrificed the best years of my life to get that M.D., and I'm entitled to wealth and social status.

Phil Schoenfeld, a senior at Penn, has already been accepted by Penn Medical School. He has a reputation for having taken no prisoners in the library. "I was probably the most grade-conscious person in the university," Schoenfeld says with a smirk. "It's easy to be a little bit calm about it now, but I was nastier then. That was a difficult period to go through." On the outlook of those with whom he has competed for four long years, Schoenfeld says, "There's a feeling you get that some of them think the world owes them something.... It does change a fair number of people."

Nurturing the nightmare

Who is to blame for the premed mess?

The medical schools often blame the colleges, which in turn complain that it's the medical admissions officials who set all the rules. Both argue that students suffer from self-induced paranoia. There is some truth in all three explanations.

Little need be said about professors who aggravate premeds' misery by singling them out for

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