[The following notes were generated by Tracey A. H. Taylor, Ph.D.]

Academic Readiness for the Pre-clerkship Curriculum: A closer look at the metrics in pathway students

In the fourth session of the series, the speaker was Stephen Schneid, the Director for Educational Development and Scholarship at the University of California, San Diego (UCSD) School of Medicine and Skaggs School of Pharmacy and Pharmaceutical Sciences. He is also the lead instructor for the UCSD Division of Extended Studies. The title of this session was “Academic Readiness for the Pre-clerkship Curriculum: A closer look at the metrics in pathway students”.

Stephen Schneid first discussed academic readiness for the preclinical medical curriculum by describing two major pathways to medical school: (1) pre-college, followed by college [usually four years and includes prerequisites, the Medical College Admissions Test (MCAT), and apply to medical school], followed by Undergraduate Medical Education (UGME; pre-clerkship and clerkship phase, licensure exams and applying for residency), and then the Graduate Medical Education (GME) phase; and (2) a second pathway involves a gap between the college and UGME phases. Some students need “something” to help them to gain entry to medical school during that time, including Postbaccalaureate Premedical Program (PBPM) and/or Prematriculation courses. PBPM is the focus for this session. Mr. Schneid summarized some data from American Association of Medical Colleges (AAMC) data reports that focus on the timing of the curriculum structure, specifically the length of the pre-clerkship phase, which is often two years but can be 18 months or even one year in length¹. This is the time when the information flow rate of curricular content is very high. The high flow rate is overwhelming to some students, especially when they are also learning new methods of studying, managing life changes, and learning time management. The pre-clerkship medical curriculum consists of the biomedical sciences, the clinical sciences, and the emerging field of health system sciences, and academic readiness is important for students to be successful. There are several ways to assess student progression: pre-clerkship academic performance (often pass/fail), graduation rates, attrition rates, time to graduation, and United States Medical Licensing Exam (USMLE) step 1 (now pass/fail). The most recent pass rate for first time test takers of USMLE Step 1 in 2022 is 93% in US and Canadian Medical schools, which is slightly below the historic pass rate of approximately 96%, dating back to 2012².  The four-, five-, and six-year graduation rates from the AAMC have been steady over time from 1997 to 2017³. Finally, attrition rates for US medical schools (AAMC) can be due to academic or non-academic factors for any MD or combination MD program, and these rates are low³.

Academic readiness is important for all of these metrics, but individual schools can also affect student success with curricular structure, assessment structure and systems, availability of learning specialists, tutoring programs, third party resources, and other factors. The AAMC core competencies for entering medical school include four thinking/reasoning competencies (critical thinking, quantitative reasoning, scientific inquiry, and written communication) and two science competencies (living systems and human behavior)⁴. Other competencies include reliability/dependability, resilience/adaptability, and capacity for improvement. Mr. Schneid discussed two major academic metrics that can be used to assess these various competencies: grade point average (GPA; including cumulative total; cumulative biology, chemistry, physics and math or BCPM; grade trend, and PBPM GPA) and MCAT (score range 472-528). The validity of the new MCAT exam for predicting student performance was evaluated and demonstrated that the MCAT gives a strong sense of academic readiness, and is predictive of academic success after year one of medical school in the medical schools involved in the study⁵. A more recent study evaluated MCAT scores with academic success in the pre-clerkship years, USMLE step 1, clerkship performance, and USMLE Step CK at several medical schools and found a similar pattern of the MCAT being predictive of academic success using median correlation scores⁶. AAMC data supported these trends that higher MCAT scores and higher GPAs were associated with a higher acceptance rate to medical school⁷. 7% of applicants with GPAs 3.00-3.19 and MCAT scores 494-497 were admitted into at least one medical school while 25% of applicants with GPAs 3.20-3.39 and MCAT scores 502-505 were admitted into at least one medical school. Success in PBPM programs can result in students earning a higher GPA, and also a higher MCAT score, thereby increasing the chances of successful admittance to medical school.

Mr. Schneid next provided an overview of postbaccalaureate premedical (PBPM) programs. According to the AAMC database, PBPM Programs are increasing, with 314 programs in 2023 compared with only 117 in 2006⁸. These programs provide a pathway for students that may not exist otherwise⁹. There are two main types of PBPM programs: academic record-enhancer programs (ARE), and career changer (CC) programs; and some programs contain elements of both types. ARE programs are targeted for students who seek to enhance their GPA and MCAT scores, are more likely to have formal curricula, and make up approximately 39% of PBPM programs¹⁰. CC programs are targeted for students who have not completed premedical coursework, are more likely to have personalized learning plan curricula, and make up approximately 27% of PBPM programs¹⁰. Interestingly, 7.1% of 2022 US medical student matriculants participated in an ARE program, while 7.7% participated in a CC program¹¹. Some specialized PBPM programs focus on underrepresented students and/or students from educationally or economically disadvantaged backgrounds⁸. Of these Diversity-based mission PBPM programs, 89% require an interview, 56% require a demonstrated commitment to underserved communities, and 28% contain a service learning requirement¹¹. When looking at matriculating student questionnaire data and PBPMs, nearly 25% of students were Underrepresented in Medicine (URiM), indicating that PBPMs may be an important pathway for URiM students to medical school¹². Graduates from one diversity-based mission PBPM program were more likely to practice medicine as primary care physicians (49.1% of graduates), and more likely to practice medicine in health professional shortage areas or medically underserved areas/populations (82% of graduates), indicating the important impact of these types of programs¹³. It is difficult to find publications indicating how PBPM students perform in medical school, however one study found that CC PBPM program students show a small but persistent academic lag in the first two years of medical school and in USMLE Step 1 scores compared with traditionally prepared students, but that the difference disappears for Step 2CK¹⁴.

The University of California, San Diego (UCSD) one-year ARE PBPM Program was created in 2012¹⁵. The program consists of foundational science courses, MCAT preparation, workshops, UCSD school of medicine faculty advisors, PBPM Program student liaisons, and a program committee letter of recommendation that is provided to each graduate for applying to medical school¹⁵. Schneid’s group analyzed PBPM student metrics at UCSD school of medicine, and compared to students who did not complete a PBPM¹⁶.  PBPM students were more likely to be URiM (32% vs 16%), and the PBPM student MCAT percentile means were only slightly lower than non-PBPM students (85.0 vs 91.7)¹⁶. Pre-clerkship performance was similar (82.6% for PBPM vs 84.9% for non-PBPM), as were USMLE step 1 scores (226 for PBPM vs 236 for non-PBPM). However, all PBPM students passed step 1, while 1% of non-PBPM students did not pass step 1¹⁶. Among the variables, MCAT and PBPM program GPA contributed significantly to the prediction of pre-clerkship performances and USMLE Step 1 scores. Overall, this data show that PBPM students demonstrate academic readiness for medical school.

Stephen Schneid’s major take-aways were that a higher proportion of UCSD school of medicine students from PBPM programs were URiM and social science majors; and that while PBPM program students at UCSD school of medicine had lower GPAs and MCAT scores, they performed well academically. The PBPM program GPA can provide important information about a student’s academic readiness as it is a more recent snapshot than cumulative GPAs. Medical schools and other health professions programs should take a closer look at applicants from PBPM programs. PBPM programs add an important lane on the road to medical school and other health professions programs for students.

References:

1. https://www.aamc.org/data-reports/curriculum-reports/interactive-data/structure-pre-clerkship-curriculum
2. https://www.usmle.org/early-release-usmle-step-1-2022-summary-performance
3. https://www.aamc.org/media/48526/download
4. https://www.aamc.org/services/admissions-lifecycle/competenciesentering-medical-students
5. Busche K, Elks ML, Hanson JT, et al. The validity of scores from the new MCAT exam in predicting student performance: results from a multisite study. Acad Med. 2020;95:387-395.
6. Hanson JT, Busche K, Elks ML, Jackson-Williams LE, Liotta RA, Miller C, Morris CA, Thiessen B, Yuan K. The Validity of MCAT Scores in Predicting Students’ Performance and Progress in Medical School: Results From a Multisite Study. Acad Med. 2022 Sep 1;97(9):1374-1384. doi: 10.1097/ACM.0000000000004754. Epub 2022 May 24. PMID: 35612915.
7. https://www.aamc.org/media/6091/download?attachment
8. https://mec.aamc.org/postbac/#/index
9. McDougle L, Way DP, Lee WK, et al. A national long-term outcomes evaluation of U.S. premedical postbaccalaureate programs designed to promote health care access and workforce diversity. J Healthcare Poor Underserved. 2015;26(3):631-647.
10. https://www.aamc.org/data-reports/students-residents/report/matriculating-student-questionnaire-msq
11. Association of American Medical Colleges. (2018). Postbaccalaureate Premedical Programs in the U.S.: Results of a National Survey. AAMC Analysis in Brief, 18(6).
12. Andriole DA, Jeffe DB. Characteristics of medical school matriculants who participated in postbaccalaureate premedical programs. Acad Med. 2011;86:201-210.
13. Smitherman HC, Aranha ANF, Matthews D, Dignan A, Morrison M, Ayers E, Robinson L, Smitherman LC, Sprague KJ, Baker RS. Impact of a 50-Year Premedical Postbaccalaureate Program in Graduating Physicians for Practice in Primary Care and Underserved Areas. Acad Med. 2021 Mar 1;96(3):416-424.
14. Baill, I. C., Khallouq, B. B., Joledo, O., Jacobs, A., Larkin, R., & Dil, N. (2019). How postbaccalaureate career changer and traditional medical students differ academically. Southern Medical Journal, 112(12), 610–616.
15. Schneid SD, Fricovsky ES, Loehr PG, Kim JG. A pipeline for health systems science in postbaccalaureate premedical programmes. Med Educ. 2022 May;56(5):568-569. doi: 10.1111/medu.14757. Epub 2022 Mar 4. PMID: 35244222.
16. Schneid SD, Kelly CJ, Brandl K. Relationships between preadmission variables and academic outcomes for postbaccalaureate students in medical school. Adv Health Sci Educ Theory Pract. 2022 Oct;27(4):1033-1048.