Abstract
The Association of American Medical Colleges recommends students seeking to enter medical school complete courses in the social sciences. Despite calls to teach social science—including anthropology—in pre-medical curriculum, little is known about what is taught in undergraduate medical anthropology courses and if concepts taught in those courses addresses topics tested in the MCAT exam. Given the growing number of anthropology students in baccalaureate allied health fields, there is a growing need to examine if anthropological coursework addresses relevant MCAT topics. Using a mixed methods content analysis, this study examined syllabi from forty U.S.-based medical anthropology courses to assess if MCAT concepts are taught in Medical Anthropology courses. Survey data was examined using descriptive statistics; syllabi were analyzed with NVivo using a binary coding scheme and modified grounded theory. Overall, only 8.69% of 155 possible concepts and terms from the Psychological, Social, and Biological Foundations of Behavior section of the MCAT were present in the syllabi. We close with considerations for future course design of medical anthropology courses.
Introduction
The Association of American Medical Colleges recommends that students seeking to enter medical school programs complete courses in the behavioral and social sciences during their baccalaureate education and prior to taking the Medical College Admission Test (MCAT). 1 Despite ongoing calls to teach social science content—including anthropological perspectives 2 —in pre-medical curriculum, little is known about what is taught in undergraduate medical anthropology courses and whether concepts taught in those courses addresses topics tested in the MCAT.
The MCAT addresses 4 broad sections: biology, chemistry, behavior, and critical thinking skills. The behavior section, “Psychological, Social, and Biological Foundations of Behavior,” was added in 2015 in recognition that behavioral and socio-cultural factors, along with biological factors, are major influences on health and illness. 3 While many of the topics tested in the MCAT may be addressed in medical schools, students are expected to have gained a foundational working knowledge of them through undergraduate or graduate coursework. Given the growing number of anthropology students in baccalaureate allied health fields, there is a growing need to examine if anthropological coursework addresses relevant MCAT topics.
This study examined syllabi from 40 U.S.-based medical anthropology courses to asses if they teach content that is tested on the MCAT. There are 4 purposes to this research. First, this research seeks to understand who teaches medical anthropology courses, the types of intuitions that teach it, and if the courses are intended for pre-medical students. Second, while there is some disciplinary discussion about syllabi5,6 this study provides the first systematic analysis of medical anthropology course content. Third, this research seeks to examine if medical anthropology courses teach content tested in the “Psychological, Social and Biological Foundations of Behavior” section of the MCAT. 4 In doing so we hope to provide a baseline from which to examine future pedagogical trends and teaching needs. Finally, we aim to facilitate a conversation regarding the tension between course design and standardization of medical anthropology.
The MCAT exam
The MCAT test addresses 5 subject areas: “Biological and Biochemical Foundations of Living Systems,” “Chemical and Physical Foundations of Biological Systems,” “Psychological, Social, and Biological Foundations of Behavior,” “Scientific Inquiry and Reasoning,” and “Critical Analysis and Reasoning.” The “Psychological, Social, and Biological Foundations of Behavior” section of the MCAT contains 5 “foundational concepts.” 4 Each foundational concept has a series of content categories. Within each content category are topics and subtopics with additional specificity. To test knowledge of these concepts, test takers are presented with paragraph-length vignettes illustrating a specific behavioral and social science construct, followed by several multiple-choice questions covering the 6 content areas. For example, the section that addresses Concept 9, cultural and social differences influence well-being, might ask questions about “medicalization” or “the sick role.”
The new behavioral sections of the MCAT were added in recognition that behavioral and social factors affect health. In a 2011 report, Behavioral and Social Science Foundations for Future Physicians, the Association of American Medical Colleges stressed that health is influenced not only by biology and genetics, but human behavior, interpersonal relationships, cultural practices, and the physical environment in which humans reside. 1
Medical anthropology and the MCAT
The AAMC encourages students to complete a variety of social science courses prior to taking the MCAT in order to learn exam content. Despite this, both the MCAT committee and the AAMC have recognized that future physicians still need standardized training in behavioral and social sciences before and during medical school to increase doctors’ general knowledge in those areas. 5
Medical anthropologists and the courses they offer are ideally positioned to teach students a variety of sociocultural topics. 6 Anthropologists regularly research, work, and teach in health services research. They have an unprecedented opportunity to contribute to medical arenas, particularly since their research directly addresses so many of the MCAT’s foundational topics. Yet, as anthropologists have pointed out, “making the most of anthropology’s particular strengths will require overcoming a series of challenges, particularly in how we as anthropologists communicate with other health professionals.” 7 This research will not only assess the content of medical anthropology courses and MCAT testing content, but will encourage medical anthropologists to discuss the transdisciplinary future of anthropology with professionals in the medical field.
Attempts to integrate medical anthropology as a recommended discipline for baccalaureate students have been unsuccessful. The Society for Medical Anthropology 8 unsuccessfully petitioned the MCAT to include medical anthropologists in the design process with the hope that medical anthropology topics would be included in the exam. 9 Despite this shortcoming, the SMA created a subcommittee in 2017 to promote medical anthropology courses. Individuals on the committee believed that their medical anthropology courses were useful for pre-med students who planned on taking the MCAT, however, the subcommittee was short-lived, and little came of it.
Syllabi content evaluations
Syllabi serve as a permanent record of a course, as a teaching tool, and to provide context to the course content so that students understand where a course fits in with other courses they have taken or will take. 10 Content evaluations of syllabi are generally conducted to better understand pedagogical trends, 11 learning objectives, 12 instructional strategies, 8 to assess similarities in course content across syllabi13,14 and to better understand course content. 13 Syllabi are examined using qualitative coding software to rank or thematically examine content. Content evaluations often result in calls to minimize variation between similar courses or to standardize topics across disciplins.11,15,16
Methodological Approach
The protocol for this study was approved by the Western Washington University Human Subjects Review Board (EX18-084). The collected survey responses and syllabi were kept in a university server in an encrypted and password protected file.
This research utilized a mixed methods approach using Qualtrics XM and NVivo. 17 A Qualtrics XM survey was used to upload syllabi from professors that have taught a medical anthropology course, broadly defined, within the previous two years. The survey was announced and distributed via the Society for Medical Anthropology email list, website and on Twitter. The survey also asked questions regarding course information, professor and institution demographic information, and required an uploaded copy of the respondent’s most recent syllabus. Given the small number of complete responses (n = 40), descriptive statistics were used to analyze the survey.
NVivo, 18 qualitative analysis software, was used to organize, qualitatively code, and analyze the syllabi. Relevant MCAT terms and concepts were coded using a binary of present (1) or absent (0) based on whether the content was stated explicitly or if was indicated by an obvious synonym. Other coded content includes titles, learning objectives, assignments, pedagogical resources, weekly themes, and specific MCAT content.
To analyze trends in course titles, titles were coded for either “Medical Anthropology” or “other titles” when there were variations such as “Culture Health and Healing.”
“Learning Objectives” were defined as “the knowledge, skills, attitudes, and habits of mind that students take with them from a learning experience.” 19 An objective was coded as present if it identified a level of knowledge, skill, attitude, or habit that the student should acquire/develop upon completing the course successfully. Although “goals” and “objectives” have a different pedagogical definition, anything fitting the broad definition of learning objectives was categorized within ‘‘Learning Objectives,” even if it was listed in a course goal. This was done in recognition that syllabi reflected conceptual and/or terminological confusion between course “goals” and learning “objectives” (eg, the syllabus listed “goals” but meant “objectives,” a methodological concern recognized in other studies. 11
“Assignments” were defined as any task that was used to evaluate student learning, such as papers, presentations, participation, fieldwork or exams. A subcategory provided greater specificity: written assignments were coded further based on length (greater than or less than 8 pages) and type (blog post, reflection, reading response, etc.), presentations were coded based on modality (individual and/or group), and exams were coded based on length (eg, a quiz vs midterm or final exam). When students could present a topic either individually or in a group, this was coded as a group project.
“Pedagogical resources” were defined as any material used for instruction and include books, book chapters, blogs, films, journal articles, magazine articles, newspaper articles, and radio shows or podcasts. A subcategory of “required reading” or “suggested reading” allowed ranking of required books by frequency.
We coded “Weekly Topics/Themes” in syllabi using the MCAT’s “Foundational Concepts” in the Psychological, Social, and Biological Foundations of Behavior section of the MCAT as reference. Sub-topics addressed in categories 6 through 10 were coded as present if a specific term was listed on the syllabus or if a topic of the term could be extrapolated from the weekly theme. For example, if a syllabus sub-topic theme listed “religiosity,” the MCAT category containing “Religion” was coded as present. For additional accuracy, we manually interpreted and coded terms rather than utilize NVivo’s ability to auto code words or synonyms.
The qualitative codes were quantified to calculate average representation of MCAT terms for each category, MCAT “Foundational Concepts” and overall representation. Calculations were completed as follows: (a) Average of Represented terms on subsections: Average of coded MCAT terms for the subsection; (b) Average of Represented Terms in Foundational Concept: Average of coded MCAT terms in all Foundational Concepts; (c) Overall Average of Represented Terms: Average of coded terms from all subsections. For example, to calculate the overall representation of MCAT categories indicated on syllabi, the total number of MCAT terms (n = 155) was multiplied by the number of syllabi (n = 40) for a total of 6200 possible references. This number was then divided by the actual number of coded references per syllabus for the average overall representation.
Results
Professor and course profiles
Most respondents identified as female (n = 28, 70.0%), white (n = 30, 75.0%) and either tenured (n = 17, 42.5%) or in a tenure track position (n = 13, 32.5%) (See Table 1). The majority of professors taught at PhD granting public institutions (n = 24, 60.0%). The vast majority of courses were taught within the discipline of Anthropology (n = 28, 70.0%). Only 40% (n = 16) of the courses were called “Medical Anthropology,” and the remaining 60% were variations of the title (i.e. Culture Health and Medicine, Culture Health and Healing).
Respondent demographic characteristics.
Most courses did not require any prerequisite (n = 27, 68%) and were for undergraduate students (n = 28, 70.0%) in any year of their education (n = 18, 45.0%) (See Table 2). The vast number of professors responded that they perceived that their students would enter a graduate, medical, or health related field (See Table 3) yet only 18% (n = 7) of respondents reviewed MCAT requirements prior to course development.
Department and course information.
Perceived student trajectories.
Pedagogical resources
One-half of the courses (25%, n = 20) required 2 or 3 monograph-length ethnographies in their courses, though textbooks were also frequently used (see Table 4 for the most frequently used books). Other resources used included journal articles, films, book chapters, and an assortment of other materials such as newspaper articles, podcasts, or magazine articles. There was not a significant difference between professors that taught at public versus private institutions regarding the use of required books (n = 21, 52.0%) or journal articles 47.5% (n = 19).
Required books.
Learning objectives
Twenty-eight (70.0%) professors listed learning objectives within their syllabi (See Table 5). Seven (17.5%) syllabi listed 1 or 2 learning objectives; 13 syllabi (32.5%) listed 4 or 5 learning objectives; 8 syllabi (20.0%) listed 6 or more learning objectives; twelve syllabi (30.0%) did not list any learning objectives. The modal number of learning objectives was zero (n = 12), followed by 5 learning objectives (n = 7). Professors at public institutions were slightly more likely to list learning objectives (n = 15, 37.5%) in comparison to professors at private institutions (n = 13, 32.5%). Throughout the vast majority of syllabi students were provided with learning objectives, none mentioned MCAT requirements or competencies.
Learning objectives.
Assignments
Syllabi listed a variety of assessment methods (See Table 6). Fieldwork assignments were present in 75% (n = 30) of syllabi. Short (shorter than 8 pages) and long papers (longer than 10 pages) were used in 85% of courses (n = 34). Quizzes (22.5%, n = 9), exams (60%, n = 24), and presentations (45%, n = 18) were also common forms of assessment. Attendance, participation, and engagement was assessed in 75% (n = 30) of courses.
Assessment methods.
Weekly class topics and the MCAT categories
A word frequency analysis of the weekly themes did not present any trends in weekly topics (See Table 7). There was only one mention of the MCAT in a syllabus. The description of a fieldwork assignment in the syllabus stated,
“This exercise will prepare you to examine alternative views of health care problems and solutions from the perspective of diverse consumers and providers of health care. It will help prepare for the socio-cultural and behavioral determinants of health and health outcomes in the new MCAT, for those pursuing training in the medical professions, enhance critical reasoning skills and develop cultural sensitivity.” (italics added for emphasis)
Word frequency of weekly class themes only words with more than 1 instance in a syllabus are included in this table.
Overall, only 8.69% of the possible 155 concepts and terms from the Psychological, Social, and Biological Foundations of Behavior section of the MCAT were represented on the 40 syllabi. The following sections and sub-sections of the MCAT were represented on the syllabi as follows.
The Foundational Concept 6 on Biological, Psychological, and Sociocultural factors considers the “ways that individuals perceive, think about, and react to the world,” resulted in an average syllabi representation of 1.6% (n = 33). Sub content category 6A, Sensing the Environment, did not have any representation. Sub content category 6B, Making Sense of the Environment, resulted in a syllabi coverage of 1.36% (n = 22). Content category 6C, Responding to the World, resulted in syllabi coverage of 4.75% (n = 19).
Foundational Concept 7, that Biological, Psychological, and Sociocultural factors influence behavior and behavior change, resulted in foundational syllabi coverage of 4.07% (n = 88). Sub content category 7A, Individual Influences of Behavior, resulted in a syllabi coverage of 3.75% (n = 33). Sub content category 7B, Social Processes that Influence Human Behavior, resulted in a syllabi coverage of 7.63% (n = 55). Sub content category 7C, Attitude and Behavior, did not have any representation on syllabi.
Foundational Concept 8, Psychological, Sociocultural, and Biological factors tests how “we think about ourselves and others, as well as how we interact with others,” and resulted in an average foundational syllabi coverage of 10% (n = 164). Sub content category 8A, Self-Identity, resulted in a syllabi coverage of 12.14% (n = 34). Sub content category 8B, Social Thinking, resulted in syllabi coverage of 9.38% (n = 45). Content category 8C, Social Interactions, resulted in a syllabi coverage of 9.43% (n = 83).
Foundational Concept 9, Cultural and Social Differences Influence Well-being, resulted in a syllabi coverage of 19.08% (n = 290). Sub content category 9A, Understanding Social Structure resulted in an average syllabi coverage of 16.3% (n = 163). Sub content category 9B, Demographic Characteristics, and Processes resulted in an average syllabi coverage of 24.42% (n = 127).
Foundational Concept 10, Social Stratification and Access to Resources Influence Well-being, resulted in 19.25% (n = 77) representation on syllabi. Sub content category 10A, Social Inequality displayed an average syllabi coverage of 19.4% (n = 77).
The usefulness of MCAT resources
Less than one quarter of the professors surveyed reported reviewing MCAT content when developing their course content (n = 7, 18.0%). However, over half of the professors believed that it would be useful for future course development if organizations such as the Society for Medical Anthropology or the American Medical Association provided information regarding MCAT requirements (n = 23, 58.0%).
Discussion
A primary goal of this study was to examine if U.S.-based Medical Anthropology syllabi contain content tested by the Psychological, Social, and Biological Foundations of behavior section of the MCAT. Other purposes include providing an empirical evaluation of how courses are taught and to promote a discussion on what medical anthropologists teach in their courses. In this discussion, we provide a series of recommendations or topics for broader discussion and future consideration.
The survey indicated that professors that teach medical anthropology courses lack diversity, a concern considering calls to diversify medical education. Responses to the survey indicate that medical anthropology professors are overwhelmingly white women. While the hiring trends in biological anthropology do indicate more women are hired in comparison to men, 20 the number of diverse faculty, using any other metric (eg, ethnicity, non-binary gender identity, ability, etc.), are lacking. As has been discussed elsewhere, we recognize that the lack of diversity among faculty that teach medical anthropology is a concern. In regards to diversity within science and medicine, we agree with others that there are “underlying issues of recruitment and retention in the STEM sciences generally” more specifically because of “the history of Anthropology particularly around questions of race-science, and to the absence of Anthropology at many minority-serving institutions, especially HBCUs, a situation that forestalls pathways to the discipline for many minority students.” 21
Even though medical anthropology is an advanced subspecialty of anthropology, the majority of the courses were offered to students in all years of their education. Given ongoing calls for increased social science and humanities training in medical education,22,23 consideration should be given to offering tiered medical anthropology courses over a student’s career, including an introductory course that incorporates MCAT concepts, and an advanced course that critiques them. If offered early in a biomedical or biocultural degree program, such a course could instill in students a recognition of the strength of medical anthropology in biocultural/biomedical disciplines. Finally, a senior medical anthropology themed capstone course, a holistic course where the entirety of a student’s education coalesces into a singular advanced experience, 24 could then be offered to provide additional subdisciplinary focus prior to entering medical school.
Learning objectives, though viewed by the authors as a tedious accreditation requirement, do help students understand the goals of a course, and in the current study, if MCAT content is addressed. Almost all of the reviewed syllabi contained learning objectives, though not all of the objectives were useful for both faculty and students. Course goals and learning objectives overlapped and many objectives were written poorly or without clarity. Many objectives were not linked to a specific competency that students were expected to gain in the course. Additionally, many objectives listed “fundamental concepts,” which upon review were exceptionally advanced and required extensive background knowledge of cultural anthropology.
It is not unexpected that the MCAT was omitted from the learning objectives given that only 18% (n = 7) of the faculty reviewed any MCAT exam content. What was unexpected, however, was that nearly all professors surveyed believed that students in their courses were entering health-related fields, including medical school. We encourage medical anthropology faculty to review MCAT testing requirements in order to develop courses that support categories, content, and vocabulary tested in the exam, along with critiques of those categories, and indicate as much in their objectives. We recognize that the strength of the broad and expansive discipline of medical anthropology lies precisely in the ways it departs from standard biomedical practice and testing. However, if medical anthropology wishes to walk in step with the MCAT content, or at least seem relevant to students that will take the MCAT, courses should be designed with MCAT content in mind.
Weekly topics were incredibly diverse and wide-reaching and recurrent themes were not observed. There were no similarities in word frequency of weekly themes, though there were some more frequently used terms and concepts. Culture, disease, illness, body, and global (or variations of each term) were frequently used in weekly themes. While this may be due to the specialty of the faculty teaching the courses, we argue below that courses should be standardized, at least at the introductory level.
Possibly a reflection of who is teaching medical anthropology courses, it appears that few of the top 17 books used in medical anthropology courses were written by faculty of color. However, nearly half of the texts used were likely written by women. With nearly all courses using a text, and given the politics of citation and representation that are recognized in our discipline, 25 we encourage future courses to include texts by faculty of color. As medical anthropology is still developing as a sub-discipline, a diversification of faculty and educational background for incoming professors can further promote the merging of content covered in the MCAT and medical anthropology coursework.
Should medical anthropology courses be standardized?
Standardization of medical anthropology course content may improve the consistency and public relevance of medical anthropology courses, as was the case for other disciplines.14-16 To an extent, a degree of standardization already exists between different medical anthropology courses nationwide. Despite the poor coverage of most MCAT topics in medical anthropology syllabi, the MCAT topics “health disparities,” “globalization,” and “health and medicine as social institutions,” were present in nearly 75% of the syllabi. But when contextualized within the entirety of the Psychological, Social, and Biological Foundations of behavior section of the MCAT, these 3 topics only represent a small fraction of concepts in the section.
There are several topics within the Psychological, Social, and Biological Foundations of behavior section of the MCAT that could be explored in detail in medical anthropology courses. Developing course topics and content that maximize content coverage overlap with MCAT testing concepts, such as further exploring social institutions, (shifting) demographics, and social class/inequality will further the integration of social science into clinical medicine by incentivizing pre-med students to take medical anthropology, therefore ensuring a future application and the relevance of medical anthropology within western clinical medicine.
Limitations
It is possible that content was undercounted in this analysis. This may have occurred for several reasons. First, it is possible that some anthropology programs address MCAT content in other courses that do not fall under the title of “Medical Anthropology.” For example, a program may offer a global health course along with a medical anthropology course, each with a slightly different focus. Second, an instructor may address a topic but not include it on a syllabus. Similarly, students, through final paper or presentation assignments, may address a topic that is not found on the syllabus. Third, there are potential methodological limitations when conducting a content analysis. 11 It is possible that class topics, as listed on the syllabus, might not adequately describe what was taught. This study coded content using MCAT vocabulary and concepts, and it is possible that the term on the syllabus did not sufficiently match the term on the MCAT. For example, if a syllabus stated “inequality: race, gender, maternal and child health” as a weekly topic, we coded the content as the MCAT category “Health Disparities” and it is possible that the categories we chose did not fully capture the breadth of the topic addressed in the courses. Conducting interviews with professors could address some of these concerns, while also shedding light on the decisions faculty made regarding selection of readings and associated educational materials.
Future Directions
This paper provides a foundation for further research on teaching medical anthropology. Several suggestions emerge from this research. Offering 2 medical anthropology courses, instead of one, may allow instruction room for MCAT content while providing an opportunity to teach specialized and advanced courses. Clearly written objectives and outcomes will provide a better understanding of medical anthropology and if MCAT content will be included. Assigning readings from faculty of color, if not supporting diverse faculty, will enhance pedagogical diversity. These suggestions could be explored in further detail to understand if they improve scores on the Psychological, Social, and Biological Foundations of Behavior section of the MCAT.
Future research would also benefit from learning more about the instructors of medical anthropology courses. Medical anthropology is still relatively new and changing. The academic background of faculty that teach courses in this subdiscipline may shed light on what is taught under the broad header of medical anthropology. If the faculty that teach these courses believe that they are relevant to students entering medical school, it would be useful to know if faculty training matches the perceived goal.
We hope that this paper helps to promote discussions about medical anthropology curricular needs. Should our sub-discipline offer introductory and advanced medical anthropology courses? Should we offer different courses for different student trajectories? Discussing these questions may enhance our understanding of the discipline as well as pedagogical questions. If medical anthropology is indeed an underutilized resource, as the Society for Medical Anthropology argues, the examination of our courses may shed light on its perceived and actual utility in years to come.
Footnotes
Acknowledgements
The authors would like to thank the the professors that participated in this research. Tyler J Stodola would like to thank Sean P Bruna for taking on this project and providing mentorship. He would also like to thank his wife, Pashience, for her support and encouragement.
Funding:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Western Washington University Mini-Research Grant and the Department of Anthropology Student Research Fund.
Declaration of conflicting interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Author Contributions
TJS and SPB designed the study, framework, analysis, data collection and drafting the manuscript. SPB applied for research funding. TJS conducted the analysis and SPB provided secondary coding and analysis. All authors have approved the final version of the manuscript.
