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Medical College Admission Test

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Medical College Admission Test
AcronymMCAT
TypeComputer-based standardized test
AdministratorAssociation of American Medical Colleges
Skills testedPhysical sciences, biological sciences, verbal reasoning
PurposeAdmissions to medical colleges
Year started1928; 96 years ago (1928)
Score range118–132 for each of four sections, totaling 472–528[1]
Score validityUsually 2 to 3 years[2]
Offered25 times from January 2017 through September 2017[3]
Restrictions on attemptsMaximum of three times in a one year period; four times in a two year period; and seven times for life[4]
RegionsMainly United States and Canada, in addition to 19 other countries[5]
LanguagesEnglish
PrerequisitesPreparing to apply to a health professional school (fluency in English is assumed)[6]
FeeUS$310–US$460[7]
("Fee Assistance Program" available to U.S. citizens, permanent residents or refugees, demonstrating financial need.[8])
Used byMedical colleges (mostly in United States and Canada)
Websitestudents-residents.aamc.org/applying-medical-school/taking-mcat-exam/

The Medical College Admission Test (MCAT; /ˈɛmkæt/ EM-kat) is a computer-based standardized examination for prospective medical students (both Allopathic M.D. and Osteopathic D.O.) in the United States, Australia,[9] Canada, and the Caribbean Islands. It is designed to assess problem solving, critical thinking, written analysis and knowledge of scientific concepts and principles. Before 2007, the exam was a paper-and-pencil test; since 2007, all administrations of the exam have been computer-based.

The most recent version of the exam was introduced in April 2015 and takes 7+12 hours to complete. The test is scored in a range from 472 to 528. The MCAT is administered by the Association of American Medical Colleges (AAMC).[10]

History

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Moss Test: 1928–1946

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In the 1920s, dropout rates in US medical schools soared from 5% to 50%,[11] leading to the development of a test that would measure readiness for medical school. Physician F. A. Moss and his colleagues developed the "Scholastic Aptitude Test for Medical Students" consisting of true-false and multiple choice questions divided into six to eight subtests. Topics tested included visual memory, memory for content, scientific vocabulary, scientific definitions, understanding of printed material, premedical information, and logical reasoning. The score scale varied from different test forms. Though it had been criticized at the time for testing only memorization ability and thus only readiness for the first two years of medical school, later scholars[who?] denied this. In addition to stricter medical school admission procedures and higher educational standards, the national dropout rate among freshman medical students decreased from 20% in 1925–1930 to 7% in 1946.[12]

A simpler test: 1946–1962

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Advancements in test measurement technology, including machine scoring of tests, and changed views regarding test scores and medical school readiness reflected the evolution of the test in this period. The test underwent three major changes. It now had only four sub tests, including verbal ability, quantitative ability, science achievement, and understanding modern society. Questions were all in multiple-choice format. Each subtest was given a single score, and the total score was derived from the sum of the scores from the subtests. The total score ranged from 200 to 800. The individual scores helped medical school admission committees to differentiate the individual abilities among their candidates. Admission committees, however, did not consider the "understanding modern society" section to be of great importance, even though it was created to reward those with broad liberal arts skills, which included knowledge of history, government, economics, and sociology. Committees placed greater emphasis on scores on the scientific achievement section as it was a better predictor of performance in medical school.[citation needed]

From 1946 to 1948, the test was called the "Professional School Aptitude Test" before finally changing its name to the "Medical College Admission Test" when the developer of the test, the Graduate Record Office (under contract with the AAMC) merged with the newly formed Educational Testing Service (ETS). In 1960, the AAMC transferred its contract over to The Psychological Corporation, which was then in charge of maintaining and developing the test.[citation needed]

Status quo: 1962–1977

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From 1962 to 1977, the MCAT retained much of its previous format, though the "understanding modern society" section was renamed as "general information" due to its expanded content. Handbooks at the time criticized the test as only a measure of intellectual achievement and not of personal characteristics expected of physicians. Admission committees responded to this criticism by measuring personal characteristics among their applicants with various approaches.[citation needed]

Phase four: 1977–1991

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During phase four, the MCAT underwent several changes. The "general information" section was eliminated and a broader range of knowledge was tested. At this point, topics tested included scientific knowledge, science problems, reading skills analysis, and quantitative skills analysis. Individual scores were reported for biology, chemistry, and physics rather than a composite science score, thus six different scores for the whole test were reported. The score scale changed to 1–15 as opposed to 200–800 from previous versions of the test. Cultural and social bias was minimized. Though the AAMC claimed the new version intended to evaluate "information gathering and analysis, discerning and formulating relationships, and other problem-solving skills", no research supported this claim.

Changes: 1991–2014

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In 1991, the test changed again. Though the test was still divided into four subtests, they were renamed as the verbal reasoning, biological sciences, physical sciences, and writing sample sections. Questions retained the multiple-choice format, though the majority of the questions were divided into passage sets. Passage-based questions were implemented to evaluate "text comprehension, data analysis, ability to evaluate an argument, or apply knowledge from the passage to other contexts." A new scoring scale was also implemented. The total composite score, which had a range of 3–45, was based on the individual scores of the verbal reasoning, biological sciences, and physical sciences, which each had a score range of 1–15. The writing sample, which consisted of two essays to be written within 30 minutes for each, was graded on a letter scale of J–T with T being the highest attainable score.[citation needed]

The exam in this format was available twice a year (April and August), lasted 8-9 hours with a lunch break, and consisted of 214 questions in addition to the essays. It took 60 days for students to receive their score.[13] On July 18, 2005, the AAMC announced that it would offer the paper-and-pencil version of the MCAT only through August 2006. A subset of testing sites offered a computer-based version of the full-length exam throughout 2005 and 2006.[14]

MR5 and the 2015 test

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The MR5 advisory committee was appointed by AAMC in fall 2008 to conduct the fifth comprehensive review of the MCAT exam and to recommend changes for the new exam set to be released in 2015.[15] The advisory committee had 21 members including medical school deans and administrators, basic and clinical science faculty, pre-health advisors, one medical student and a medical resident.[15] The recommendations determined were also based on responses from 2,700 surveys, over 75 meetings and conferences, and 90 outreach events to solicit input.[16] The recommendations considered the content and format of the MCAT, the resources that should be provided relating to the exam, and the changes that should be made to medical school admissions in general.[15]

Ratings of the Importance of Natural and Behavioral Sciences Topics for Mastery of Future Medical School Curricula[17]

To determine the content that should be tested for the exam, the MR5 committee surveyed medical school faculty, residents, and medical students, and asked what concepts entering students need to know to be successful in medical school curricula.[17] Three separate surveys were sent asking about concepts in the natural sciences, research methods, and behavioral sciences. The MR5 committee also consulted various expert committees from within and beyond the AAMC.

The largest changes in the exam consist of testing in biochemistry, psychology and sociology concepts. The addition of biochemistry material follows survey results placing biochemistry concepts as highest importance for success in future medical school curricula.[17] The addition of behavioral and cultural material was recommended to provide a solid foundation for learning of these concepts in medical school. According to the committee, psychological science should be understood by medical students as an essential aspect of healthcare.[18] The writing sample section was also removed, since data showed that these scores were not used by most admission committees.[15] These changes were revealed in 2012 so that undergraduate premedical advisers studied the MR5 documents to translate tested core competencies into premedical course recommendations at their campuses.[15]

This version of the MCAT has been administered since March 2015 and is expected to be in place until 2030.[19]

Administration

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The exam is offered 25 or more times per year at Pearson VUE centers.[20] The number of administrations may vary each year. As of the 2023 MCAT testing period, 41.8% of students take the MCAT within one year of graduation, 32% sit the exam within 1-2 years post-graduation, 13.5% take the exam between three and four years after graduation and 12.7% sit for the exam five or more years after graduation.[21]

The test, updated in 2015, consists of four sections, listed in the order that they are administered

  • Chemical and Physical Foundations of Biological Systems
  • Critical Analysis and Reasoning Skills (CARS)
  • Biological and Biochemical Foundations of Living Systems
  • Psychological, Social and Biological Foundations of Behavior

The four sections are in multiple-choice format. The passages and questions are predetermined, and thus do not change significantly in difficulty depending on the performance of the test taker (unlike, for example, the general Graduate Record Examinations). To account for slight differences in difficulty across test versions, the exam uses a scaled score for each section, converting numerical scores to a scaled score between 118 and 132 per section.[22]

Test structure

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The MCAT consists of four distinct sections that are individually scored. Each section is allotted either 90 or 95 minutes and tests between 53 and 59 questions.[23] Including breaks, the full examination lasts approximately 7+12 hours.[24] The information for each of the science sections is organized into 10 foundational concepts and four Scientific Inquiry & Reasoning Skills.[25] The science passages are guided by Scientific Reasoning and Inquiry Skills identified by the MR5 for medical school success.[19] The Critical Analysis and Reasoning Skills section focuses on three skills, since this section does not require outside knowledge to answer questions.[26]

Section Questions Minutes
Chemical and Physical Foundations of Biological Systems 59 95
Critical Analysis and Reasoning Skills 53 90
Biological and Biochemical Foundations of Living Systems 59 95
Psychological, Social and Biological Foundations of Behavior 59 95

Chemical and Physical Foundations of Biological Systems

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This section tests chemistry and physics in the scope of biological systems, requiring understanding of organic and inorganic chemistry and physics as well as biology and biochemistry. Specifically, this section focuses on the physical principles underlying biological processes and chemical interactions that form the basis of a broader understanding of living systems. Understanding of research methods and statistics are also important to successfully reason through this material.[27]

Critical Analysis and Reasoning Skills (CARS)

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The CARS section is similar to verbal reasoning sections providing passages with questions testing reading comprehension. The 500–600 word passages can cover topics ranging from the social sciences to the humanities, sometimes presenting in a convoluted or biased manner requiring the reader to consider what is being written from multiple perspectives.[26] The passages are designed to discuss topics that are unfamiliar to the reader, but success in this section requires strictly using information from the passage without using previously known knowledge.[28]

Biological and Biochemical Foundations of Living Systems

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This section mainly tests biology and biochemistry but also requires an understanding of organic and inorganic chemistry. Students will have to answer questions about the functions of biomolecules, processes unique to living organisms, and the organization of biological systems. Understanding of research methods and statistics are also important to successfully reason through this material.[27]

Psychological, Social and Biological Functions of Behavior

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This section tests psychology and sociology so that students can demonstrate their understanding of the behavioral and sociocultural determinants of health. Specific material tested include behavior and behavior change, perceptions of self and others, cultural and social differences that influence well-being and social stratification. Understanding of research methods and statistics are also important to successfully reason through this material.[27]

Scientific Inquiry and Reasoning Skills

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In the new MCAT exam, changes have been made not only in the content of the exam, but also in the way in which content is presented on the exam. MCAT questions will require examinees to demonstrate four Scientific Inquiry and Reasoning Skills that have been identified by the MR5 as crucial to success in science and medicine. The first skill is Knowledge of Scientific Concepts and Principles, which requires students to not only recognize and recall scientific information, but also to identify relationships between similar concepts. Scientific Reasoning and Problem Solving tests the student's ability to relate scientific theories and formulas to presented information to explain findings and draw conclusions. Reasoning about the Design and Execution of Research requires examinees to show that they can understand science in the context of experiments. The fourth skill of Data-based and Statistical Reasoning requires students to be able to read graphs and tables and draw conclusion from evidence.[27]

MCAT Sections with Subjects Percentage and College Prerequisites
A detailed overview of the Medical College Admission Test (MCAT). It outlines the four sections, number of questions, duration, subject percentages, and helpful college courses. It includes the highest possible and average total scores. Source: MCAT-prep.com

Scoring

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The test consists of four sections, each scored from 118 to 132 with a median score of 125.[29] The total MCAT score is a sum of the scores from each of the four sections, ranging from 472 to 528 with a median score of 500. Scores are released on a pre-determined date between 30 and 35 days after the exam date.[30]

2024 scoring percentiles

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The following are the scores, along with their percentiles from test takers from May 1, 2024, through April 30, 2025. MCAT percentiles are updated every year on May 1. The average scaled score was 500.7 with a standard deviation of 10.8.[31]

MCAT Total Score Percentile Ranks (May 1, 2024 – April 30, 2025)
Total Score Percentile Rank
472 <1
473 <1
474 <1
475 1
476 1
477 2
478 2
479 3
480 4
481 5
482 6
483 7
484 9
485 10
486 12
487 14
488 16
489 18
490 20
491 22
492 25
493 27
494 30
495 33
496 36
497 39
498 42
499 45
500 48
501 51
502 54
503 58
504 61
505 64
506 67
507 70
508 73
509 76
510 79
511 82
512 84
513 87
514 89
515 91
516 92
517 94
518 95
519 96
520 97
521 98
522 99
523 99
524 100
525 100
526 100
527 100
528 100

Policies

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Like some other professional exams (e.g. the Graduate Management Admission Test (GMAT) or the Law School Admissions Test (LSAT)), the MCAT may be voided on the day of the exam if the exam taker is not satisfied with his or her performance. It can be voided at any time during the exam, or during a five-minute window that begins immediately after the end of the last section. The decision to void can only be based on the test taker's self-assessment, as no scoring information is available at the time.[citation needed]

The AAMC prohibits the use of calculators, timers, or other electronic devices during the MCAT exam.[32] Cellular phones are also strictly prohibited from testing rooms and individuals found to possess them are noted by name in a security report submitted to the AAMC. The only item that may be brought into the testing room is the candidate's photo ID. If a jacket or sweater is worn, it may not be removed in the testing room.[33]

It is no longer a rule that students must receive permission from the AAMC if they wish to take the MCAT more than three times in total. The limit with the computerized MCAT is three times per year, with a lifetime limit of seven times.[34] An examinee can register for only one test date at a time, and must wait two days after testing before registering for a new test date.

Scaled MCAT exam results are made available to examinees approximately thirty days after the test via the AAMC's MCAT Testing History (THx) Web application. Examinees do not receive a copy of their scores in the mail, nor are examinees given their raw scores. MCAT THx is also used to transmit scores to medical schools, application services and other organizations (at no cost).

Preparation

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The average student spent 3 months preparing for the MCAT exam spending about 20 hours per week, excluding time taking regular courses.[35]

In the weeks leading up to the exam, most students take some time off to study intensely for the exam. The AAMC provides official study materials for purchase on their website with hundreds of questions written by the developers of the MCAT, including four scored practice exams and one non-scored practice exam.[36] As of the 2023 MCAT testing cycle, 89.6% of students used official MCAT Practice Exams, while 61.2% of test-takers reported using official MCAT Question Packs and 58.5% reported using official MCAT Section Banks.[37]

The AAMC also provides free online preparatory material for the MCAT through Khan Academy, including 1,000 free videos and 2,800 review questions including content review and passage-based questions.[38] In 2023, 66.3% of students responded that they used this partner material to prepare for the exam.[39]

Relevance

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Medical School Acceptance based on MCAT Scores, 2016-2018[40]

Almost all United States medical schools and most Canadian medical schools require prospective students to submit MCAT scores for their applications.[41] As of 2024, 25 allopathic and osteopathic schools offered options for acceptance to medical school without the MCAT, either through B/MD programs and/or early acceptance programs (EAPs).[citation needed] In a survey conducted by the AAMC of 130 medical schools, MCAT scores were among the most important metrics used to identify applicants to interview and admit.[42] Furthermore, in a 2017 survey by Kaplan, 54% of medical schools said that a low MCAT score was "the biggest application dealbreaker".[43] Medical school admissions is a holistic process and the AAMC provides recommendations on how MCAT scores should be used in admissions, specifically recommending that MCAT scores should not outweigh an applicant's other materials.[42]

A recent study (2016) shows a small correlation (r=.18) between MCAT scores and USMLE step 1 scores.[44] The MCAT exhibited a medium correlation (r=.32) with the Canadian Board exam in 2016, the (MCCQE-1).[45] The Biological Sciences section had been the most directly correlated section to success on the USMLE Step 1 exam in an article published in 2002, with medium-to-large correlation coefficients of .55 vs .49 for Physical Sciences and a medium correlation of .40 for Verbal Reasoning.[46]

Results from the previous version of the MCAT that was administered between 1992 and 2014 have been studied in relation to academic success in medical school and beyond. Most data suggests that undergraduate grades and MCAT scores can predict scores on USMLE Step exams.[47] Data from a cohort of 14 medical schools in 1992 and 1993 found that MCAT scores were stronger predictors of USMLE Step scores than undergraduate GPA and were also good predictors for probability of experiencing academic difficulty.[48] Data from students from 119 U.S. medical schools who matriculated between 2001 and 2004 showed that undergraduate GPA and MCAT total scores predicted unimpeded progress towards medical school graduation better than GPA alone.[49] A third study using data from students from the University of Minnesota Medical School from five graduating classes between 2011 and 2015, found that MCAT component scores were significantly associated with USMLE Step 1 and Step 2 scores, although the effect was small.[50] Higher MCAT scores are correlated with membership in the national medical honors society Alpha Omega Alpha (AOA), suggesting that MCAT scores can be useful to identify potential top-performing medical students.[51]

Since the most recent version of the MCAT exam was only released in 2015, insufficient years have passed to determine correlation between MCAT scores and medical school benchmarks. The AAMC plans to use medical school data from 2017–2021 to determine the predictive ability of the new MCAT.[42] The data will be collected from 18 medical schools who have agreed to collect data from students from entry to graduation including academic performance, USMLE Step exam scores, time to graduation and graduation rates.[48]

See also

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References

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  1. ^ "The New Score Scales for the 2015 MCAT Exam: An Overview of What Admissions Officers Need to Know" (PDF). Association of American Medical Colleges. Retrieved 29 April 2015.
  2. ^ "MCAT FAQ". aamc.org.
  3. ^ "MCAT Calendar" (PDF). Association of American Medical Colleges.
  4. ^ "MCAT FAQ". aamc.org.
  5. ^ "MCAT Testing Center Locations". services.aamc.org. Retrieved 18 March 2016.
  6. ^ "MCAT FAQs". aamc.org.
  7. ^ "Register for the MCAT Exam". www.aamc.org.
  8. ^ "Fee Assistance Program". www.aamc.org.
  9. ^ "Melbourne Medical School International Applicants". University of Melbourne. Retrieved 23 October 2015.
  10. ^ "Taking the MCAT® Exam". Association of American Medical Colleges. Retrieved 2019-07-23.
  11. ^ McGaghie, William C. (2002-09-04). "Assessing Readiness for Medical Education". Journal of the American Medical Association. 288 (9): 1085–1090. doi:10.1001/jama.288.9.1085. PMID 12204076.
  12. ^ Smedley, BD; Stith Butler, A; Bristow, LR, eds. (2004). "Reconceptualizing Admissions Policies and Practices". In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: National Academies Press (US).
  13. ^ "What is changing on the MCAT?". Kaplan Test. Archived from the original on 2007-09-28.
  14. ^ "Medical College Admission Test Will Convert to Computer-Based Format". Association of American Medical Colleges. Archived from the original on 2007-09-27.
  15. ^ a b c d e "Final MR5 Recommendations" (PDF). Association of American Medical Colleges.
  16. ^ "MR5: 5th Comprehensive Review of the Medical College Admission Test® March 2011 e-newsletter".
  17. ^ a b c "Ratings of the Importance of Topics in the Natural Sciences, Research Methods, Statistics, and Behavioral Sciences to Success in Medical School" (PDF). Wild Apricot.
  18. ^ "The teaching of psychology and the new MCAT". apa.org. Retrieved 2018-04-14.
  19. ^ a b "Final Recommendations for the 2015 MCAT Exam" (PDF). Association of American Medical Colleges.
  20. ^ "Pearson VUE to deliver Medical College Admission Test® (MCAT®) beginning in 2018". Pearson VUE. 2017.
  21. ^ Association of American Medical Colleges (2023). Post-MCAT Questionnaire 2023 Report (Report). Association of American Medical Colleges.
  22. ^ "How is the MCAT Exam Scored?". Association of American Medical Colleges. 2024.
  23. ^ What's on the MCAT Exam? (Report). Association of American Medical Colleges. 2020.
  24. ^ "The MCAT® Essentials for Testing Year 2018" (PDF). Association of American Medical Colleges.
  25. ^ "What's on the MCAT Exam?". Association of American Medical Colleges. Retrieved 2018-03-30.
  26. ^ a b "Critical Analysis and Reasoning Skills Section: Overview". Association of American Medical Colleges. Retrieved 2018-03-30.
  27. ^ a b c d "What's on the MCAT Exam" (PDF). Association of American Medical Colleges.
  28. ^ CARS overview, Khan Academy, retrieved 2018-03-30
  29. ^ "The MCAT Exam Score Scale". Association of American Medical Colleges. Retrieved 2018-03-27.
  30. ^ "U.S. MCAT Calendar, Scheduling Deadlines, and Score Release Dates". Association of American Medical Colleges. 2024.
  31. ^ MCAT Total and Section Score Percentile Ranks 2024 (Report). Association of American Medical Colleges. 2024.
  32. ^ "The MCAT Essentials for Testing Year 2016" (PDF). Association of American Medical Colleges. 2016.: 24−25 
  33. ^ "Testing Center Regulations and Procedures". Association of American Medical Colleges.
  34. ^ "MCAT FAQ". students-residents.aamc.org.
  35. ^ "When Is the Right Time to Take the MCAT Exam? Three Questions to Ask Yourself". Association of American Medical Colleges. 2024.
  36. ^ "Prepare for the MCAT Exam". offers.aamc.org. Retrieved 2018-04-16.
  37. ^ Post-MCAT Questionnaire 2023 Report (Report). Association of American Medical Colleges. 2023.
  38. ^ "MCAT Test prep". Khan Academy. 2024.
  39. ^ Association of American Medical Colleges (2023). Post-MCAT Questionnaire 2023 Report (Report). Association of American Medical Colleges.
  40. ^ "MCAT and GPA Grid for Applicants and Acceptees to U.S. Medical Schools, 2016-2017 through 2017-2018" (PDF). Association of American Medical Colleges.
  41. ^ "About the MCAT® Exam". students-residents.aamc.org. Retrieved 2018-04-15.
  42. ^ a b c "Using MCAT Data in 2018 Medical Student Selection" (PDF). Association of American Medical Colleges.
  43. ^ "Kaplan Test Prep Survey: Medical School Admissions Officers Advise Aspiring Doctors to Score High on the MCAT®, Apply Early, and Avoid Discussing Politics". Kaplan Test Prep Online Pressroom. 2017-11-27. Retrieved 2018-03-30.
  44. ^ Giordano, C.; Hutchinson, D.; Peppler, R. (2016). "A Predictive Model for United States Medical Licensing Exam (USMLE) Step 1 Scores". Cureus. 8 (9): e769. doi:10.7759/cureus.769. PMID 27738569.
  45. ^ Roy, B.; Ripstein, I.; Perry, K.; Cohen, B. (2016). "Predictive value of grade point average (GPA), Medical College Admission Test (MCAT), internal examinations (Block) and National Board of Medical Examiners (NBME) scores on Medical Council of Canada qualifying examination part I (MCCQE-1) scores". Canadian Medical Education Journal. 7 (1): e47–e56. doi:10.36834/cmej.36616. PMID 27103953.
  46. ^ Moroi, K.; Sato, T. (2002). "Undergraduate Institutional MCAT Scores as Predictors of USMLE Step 1 Performance". Biochemical Pharmacology. 24 (16). Acad Medicine: 1517–21. doi:10.1097/00001888-200210001-00005. PMID 8.
  47. ^ "Using MCAT® Data in 2018 Medical Student Selection" (PDF). Association of American Medical Colleges.
  48. ^ a b Julian, Ellen R. (October 2005). "Validity of the Medical College Admission Test for predicting medical school performance". Academic Medicine. 80 (10): 910–917. doi:10.1097/00001888-200510000-00010. ISSN 1040-2446. PMID 16186610. S2CID 11151468.
  49. ^ Dunleavy, Dana M.; Kroopnick, Marc H.; Dowd, Keith W.; Searcy, Cynthia A.; Zhao, Xiaohui (May 2013). "The predictive validity of the MCAT exam in relation to academic performance through medical school: a national cohort study of 2001-2004 matriculants". Academic Medicine. 88 (5): 666–671. doi:10.1097/ACM.0b013e3182864299. ISSN 1938-808X. PMID 23478635.
  50. ^ Gauer, Jacqueline L.; Wolff, Josephine M.; Jackson, J. Brooks (2016-09-30). "Do MCAT scores predict USMLE scores? An analysis on 5 years of medical student data". Medical Education Online. 21: 31795. doi:10.3402/meo.v21.31795. PMC 5045966. PMID 27702431.
  51. ^ Gauer, J. L.; Jackson, J. B. (2017). "Association between the Medical College Admission Test scores and Alpha Omega Alpha Medical Honors Society membership". Advances in Medical Education and Practice. 8: 627–632. doi:10.2147/AMEP.S145839. PMC 5608086. PMID 28979178.

Further reading

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