In 2015, the Association of American Medical Colleges revised the Medical College Admissions Test (MCAT) for the first time in nearly 25 years, stretching the full exam-day experience from around five hours to eight or more. The test drew attention at the time for its sheer length; less widely noted was the explicitly ideological bent of the new exam.
The AAMC occupies a curious place in the world of medicine. It forms one-half of the only government-approved accrediting entity for U.S. medical schools, and it is solely in charge of administering both the MCAT and the national standardized medical school application. Unlike the American Medical Association, which represents physician groups without exercising much direct control over doctors, the AAMC has immediate and significant authority over its constituent medical schools and academic health centers. And in recent years, it has used this leverage to fundamentally alter the way medical schools assess applicants.
Dr. Darrell Kirch, president and CEO of the AAMC, expressed his vision in a candid 2011 speech at the University of California, Davis: “I am a man on a mission. I believe it is critical to our future to transform health care. I’m not talking about tweaking it. I’m not talking about some nuanced improvements here and there. I’m talking about true transformation.”
In that address and others, he described the AAMC’s “Holistic Review Project,” which the organization launched in 2007 with the goal of “redefining what makes a good doctor.” The project’s objectives included revising the MCAT and a wide range of other reforms. A series of new guidelines (some of which have yet to be implemented) called on medical school admissions teams to place less emphasis on applicants’ grades, changed the requirements for letters of recommendation, and altered the standardized application by requesting a great deal more information about students’ upbringing and life experiences. The AAMC is also planning to add “situational judgment tests”—carefully crafted interviews in which applicants will be presented with a variety of hypothetical scenarios involving ethical conflicts—to the current admissions requirements. Along with the new MCAT, these changes are part of Kirch’s plan to shift the focus of medical-school admissions toward a “new excellence,” a standard based less on test scores and more on “the attitudes, values, and experiences” of applicants.
The AAMC has also successfully advocated for changes in medical curricula. A philosophy major, Kirch likes to tell the story of his unconventional journey to becoming a psychiatrist, stressing the importance of integrating perspectives from non-medical fields into medical training. He has repeatedly expressed his desire to move medical studies “away from the accumulation of facts” and toward “a new paradigm.” Whether this is scientifically sound or not, it has become the norm in many pre-med programs, which now offer “interdisciplinary” majors such as Columbia University’s “Medicine, Literature and Society” track or Cornell’s “Biology and Society.” A number of medical schools have also revised their mission statements to better align with the AAMC’s principles.
These changes might not seem worrisome at first glance. But when combined with Kirch’s political statements, the reforms raise questions about what the AAMC’s “new paradigm” will entail. Kirch often insists that social justice is the neglected core tenet of medical ethics; in a 2015 essay, he praised the White Coats for Black Lives movement, a medical-student organization inspired by Black Lives Matter, for “sparking dialogue rather than division” by “staging on-campus die-ins.” White Coats for Black Lives lobbies, among other things, for the creation of “national medical school curricular standards” that would mandate the teaching of “structural racism” and “unconscious racial bias” in medical schools.
Kirch has also praised the AAMC’s political advocacy efforts, which lean left on most issues. Anyone who registers to take the MCAT automatically receives frequent “action alerts” issued by the AAMC’s Government Affairs and Advocacy division, which serves as the organization’s lobbying arm. In recent months, the AAMC has weighed in on immigration reform and the Trump administration’s travel ban. Kirch once boasted, half-jokingly, that “the AAMC was the author of some of the most vague language [in the Affordable Care Act].”
But it is Kirch’s reform of the MCAT that raises the most concern. The AAMC began redesigning the test in 2009, but only received approval for the revisions in 2012. In an announcement reported by the New York Times that year, Kirch explained, “The goal is to improve the medical admissions process to find the people who you and I would want as our doctors. Being a good doctor isn’t just about understanding science, it’s about understanding people.” One new section of the exam, entitled “Psychological, Social, and Biological Foundations of Behavior,” requires test-takers to respond to multiple-choice questions in which both the question’s premise and the available answers are, at best, often distantly related to medicine.
One MCAT practice question (from a collaboration between the AAMC and online-education nonprofit Khan Academy), for example, asks whether the wage gap between men and women is the result of bigotry, sexism, racism, or biological differences (no other options are provided, and the “correct” answer is sexism). Another asks whether the “lack of minorities such as African Americans or Latinos/Latinas among university faculty members” is due to symbolic racism, institutional racism, hidden racism, or personal bias (the correct answer is institutional racism). Yet another asks test-takers to select from a list of debatable definitions for “the terms ‘sex’ and ‘gender.’ ”
Taken on their own, these questions may not seem particularly invidious. And it would be easy enough for a good test-taker to select answers that would be marked as correct, whether he or she agreed with them or not. But the changes nonetheless reflect Kirch’s greater goal: to test “not just what students know,” as he said in a 2015 interview about the test, “but how they think.”
In response to questions about these developments and their effects, the AAMC’s executive vice president, Dr. Atul Grover, referred to a set of core principles guiding the organization’s recent work. An AAMC report outlining those principles describes the organization as “a powerful voice for compassion, equity, and justice” on behalf of the nation’s academic medical institutions, and stresses the importance of “advancing a well-trained, culturally competent, and diverse health and biomedical workforce.” Grover further explained that the revised MCAT “tests students on the knowledge and skills that future physicians need to practice in a changing health care system and serve a changing patient population” and establishes a foundation for learning “about the socio-cultural and behavioral determinants of health.”
According to Grover, the periodic review and updating of standardized tests “are considered a best practice,” and the changes to the MCAT were called for “in part because the health system of tomorrow requires a different kind of physician.” He explained that the impact of these changes on applicants and medical schools is currently being evaluated by a group of 18 medical schools.
If the AAMC’s objective were merely to improve the bedside manner and general sensitivity of physicians, or even to increase diversity in the medical field through conventional affirmative-action policies, few people would likely object. Unfortunately, what Kirch in particular seems to want to create is a medical community that aligns as closely as possible with his particular political views—and to insist that future doctors accept those views as settled fact. This leaves students who don’t share Kirch’s (and the AAMC’s) transformative vision with a difficult choice: Will they violate their own integrity in order to succeed?
The AAMC is not alone among accrediting institutions seeking to steer professions leftward. The American Psychological Association, which accredits a variety of graduate-level psychology programs, has taken strong positions on topics such as pay equality and gun control. The Council on Social Work Education, which accredits college-level and graduate social work programs, has also been outspoken on a range of issues, particularly regarding “social and economic justice.” Yet this shift among medical educators is particularly alarming. One would expect the leaders of a scientific discipline to carefully distinguish between verifiable fact and opinion; the new MCAT blurs that line.
In his address at the AAMC’s most recent annual meeting, Kirch said he “refuse[s] to live in a post-truth world” and insisted that doctors cannot “let bias influence patient care.” But the AAMC’s policy of imposing political litmus tests on future physicians is contributing to this trend. Integrity is among the most important qualities a doctor can possess—it entails doing the right thing when no one else is watching. With its politically loaded MCAT questions and “holistic” admissions recommendations, the AAMC is teaching aspiring physicians to compromise their integrity and adherence to the truth before their careers even begin.
Devorah Goldman is assistant editor at National Affairs.
