Starting in the year 2015, pre-medical students will be taking the new MCAT. Pre-medical advisors, faculty, and students are just beginning to learn about the contents of the new exam, which will be 2.5 hours longer than the current one, for a total of 6 hours of testing. The new exam includes a section on the social and behavioral sciences, called “Psychological, Social, and Biological Foundations of Behavior.” This portion of the exam is intended to increase awareness within the medical community of the social, cultural, and behavioral factors that profoundly influence health, prescribed treatments, and disease outcomes. The new exam will also include biochemistry in the biological sciences section, as well as a wider range of topics from the social sciences and humanities in the verbal reasoning section, which will have a new name, “Critical Analysis and Reasoning Skills.” Additionally, the Writing Sample section will not be included in the exam, a decision that has already been implemented for the 2013 MCAT.
For students, the only information here that is probably not unnerving is the absence of the Writing Sample. However, the AAMC (Association of American Medical Colleges) website provides helpful suggestions that will prepare students for the additional knowledge required to perform well on the new exam. First-semester biochemistry, introductory psychology, and introductory sociology are strongly recommended. While some students may find this especially daunting to complete on top of the required pre-medical courses, it is helpful to realize that many medical schools currently require or strongly recommend these courses for admission. Additionally, these courses can fulfill social science or elective requirements for the undergraduate degree.
As far as taking the MCAT goes, all these changes do not affect me at all. I have already taken the MCAT and I have already applied to medical school. However, the implications of the new exam profoundly affect all physicians and physicians-to-be regardless of the stage they are up to in pursuing their medical careers. As a former pre-med student that majored in Psychology, I have taken a keen interest to the addition of the behavioral sciences section on the new exam.
Behavioral science is the study of the activities and interactions among organisms, and includes the studies of psychology, sociology, and biology. A look at the AAMC’s “Preview Guide for the MCAT 2015 Exam” reveals that the “Psychological, Social, and Biological Foundations of Behavior” section covers a wide range of topics in the behavioral sciences. Similarly to the biological and physical sciences sections on the MCAT, the behavioral sciences section will have free-standing questions as well as several passages followed by passage-based questions. In the “Preview Guide,” Sample Passage 1 of the behavioral sciences section discusses a study that was performed to assess patients’ perceptions of vulnerability to acquiring skin cancer when older. Students should understand that a study such as this one may help the medical and scientific community determine people’s tendency to exercise preventative health measures and adhere to prescribed treatments and lifestyle changes. Sample Passage 2 discusses the combined influence of genes, hormones, and socio-cultural patterns on alcohol dependence, while Sample Passage 3 discusses the effects of social Internet contacts on health-related behaviors such as maintaining a “diet diary.” Subsequent passages and free-standing questions address topics of memory, classical conditioning, Weber’s Law, social change and upward mobility – the list goes on and on.
As a physician, it is crucial to realize that health is influenced by biological, behavioral, psychological, social, socioeconomic, religious, and cultural factors, which may vary from one group to another, and from person to person. Cultural contributions to various disease processes, patient perceptions of illness, and prescribed treatments became profoundly obvious to many American physicians during the late 19th and early 20th centuries when millions of people from all over the world gained passage to America through Ellis Island and other ports throughout the country, according to Alan M. Kraut in his book, Silent Travelers. America continues to grow more and more diverse, increasing the importance placed on addressing both biological and non-biological factors when making a diagnosis and prescribing a course of treatment.
The importance of addressing both biological and non-biological influences are introduced in an introductory psychology course where students learn that possessing a Type A personality, characterized by hostility and impatience, increases the risk of cardiovascular disease. Among a host of illnesses, cardiovascular disease has also been linked to epigenetics, a situation of altered gene expression in response to environmental signals. According to Moises Velasquez-Manoff in his book, An Epidemic of Absence, the Dutch Hunger Winter of 1944-’45 demonstrates this phenomenon quite dramatically. During the Dutch Hunger Winter, Nazi forces blockaded the western Netherlands, causing famine in the region. Women who were pregnant during the mass starvation tended to birth smaller babies, who later had an increased risk for developing obesity and cardiovascular disease in adulthood. Scientists concluded that expression of genes coding for certain metabolic regulators was increased in these “famine fetuses” in order to prepare them for a world of scarcity. However, the conditions expected by their epigenome were not the plentiful conditions that they, in fact, encountered, predisposing this particular group to certain diseases. Not only is it important for physicians to address more immediate factors when assessing disease risk, such as physiological conditions or even personality characteristics, but it is also important to gather relevant information about the patient’s environmental history.
Cultural factors can also influence diagnosis and treatment of disease. For example, culture is one factor that affects a patient’s expression of pain according to the National Institutes of Health. Certain ethnic groups have a propensity for expressing pain more dramatically, while other ethnic groups are more prone to suffer silently. The Pokot people of Kenya are, perhaps, the most striking illustration of this point. They believe that stoicism in the face of pain is most honorable, while expression of pain is demoralizing and shameful. Female genital mutilation, performed on adolescent girls as a mark of womanhood, is a common practice within the Pokot community. Although this violent ritual is extremely painful, the Pokot women are strongly encouraged to show endurance and conceal their pain, something I learned during a speech delivered by a former classmate in “Speech Communication.” While this is an extreme example, expression of pain still varies between different cultures, and there is a risk that patients may go untreated depending on how pain is expressed by the patient and perceived by the physician. Physicians should be aware of these cultural differences to ensure that their perceptions are true to what the patient is actually experiencing.
The ability to cultivate a successful therapeutic relationship and effectively treat different populations requires an understanding that different cultures perceive health and disease processes differently. For example, according to the National Institutes of Health, dementia is perceived differently among various cultural groups. African Americans tend to attribute dementia to lifelong hardship and stress, whereas Asian cultures tend to perceive the disease as a result of “internal imbalances” and “lack of harmony.” The Asian perception of disease causation may stem from religious beliefs, according to one study that investigated the Asian patient population. According to Taoism, a philosophical and religious tradition that has influenced many Asian cultures, everything in the universe, including the human body, is composed of two forces, the yin and the yang. Asian groups influenced by Taoism tend to view disease as a result of imbalances between these two forces. A physician who understands religious and cultural differences in perception of disease origin is more likely to cultivate the therapeutic relationship that is necessary for successful treatment.
This point became more apparent to me after I recently spoke to a primary care physician who treats many Hasidic patients in a Brooklyn clinic. He wanted to prescribe a particular medication to a young, married, Hasidic woman. Knowing, however, that the medication could be harmful to a fetus, the physician asked her if she was pregnant. She refused to answer the question. According to the doctor, she was reluctant to reveal the pregnancy as that would violate the Hasidic code of personal modesty. Nearly all Hasidic sects view secular education as a threat to their traditional values. In order to protect their children from its harmful influences, they have established their own schools where secular studies are offered, but hardly given equal importance to the religious subjects. There is careful supervision and censorship of textbooks in the classroom to ensure that subject matter does not conflict with religious beliefs. In addition to the heavy constraints placed on secular education in Hasidic schools, the overwhelming majority of Hasidim do not pursue any form of higher education. Without any solid background in secular education, the Hasidic patient naturally chose traditional beliefs over common medical protocol. As a physician, it is important to recognize the influence of religion on perceptions of health and illness and to respond appropriately to a diverse population of different belief systems.
There are many other psychological and behavioral factors that affect health and disease such as depression, chronic stress, and risk behaviors such as tobacco use and alcohol consumption. It is crucial that physicians elicit information during the medical interview regarding such factors when assessing a patient’s health. It might be necessary to refer the patient to other professionals more equipped to treat these aspects of health with psychological therapy, recommendations for appropriate lifestyle changes, or methods of behavioral modification such as conditioning. Physicians should also be aware that affective disorders are often accompanied by physical pains, aches, and fatigue, a phenomenon known as somatization. According to the National Institutes of Health, anxiety and depression are among the most common affective disorders that go undiagnosed by physicians who fail to make this mind-body connection.
A solid background in psychology, sociology, and behavioral science is clearly a tremendous asset to any physician’s practice of medicine. However, a solid background is not enough. Studies suggest that a physician’s attitude toward psychosocial contributors to health will determine the quality of care they provide. A physician who disregards the influences of stress, family values, job-related pressures, or racial and ethnic differences may risk an ineffective and uncomfortable therapeutic relationship as well as neglect of some important aspects of the patient’s health.
The new MCAT, particularly the behavioral sciences section, is designed to impress upon students that treating the physical symptoms of disease go hand-in-hand with addressing the patient’s emotions, concerns, behaviors, and surrounding environment. While many students may view the new MCAT as another obstacle in the way of achieving their professional goals, it is worthwhile to approach the new version of the exam as an opportunity to learn the ways of being a better physician.