\begin{tikzpicture}[>=stealth']
  \node (dependent) at (0,4) {dependent};
  \node (ready) at (0,2) {ready};
  \node (premed) at (0,-2) {premed};
  \node (med) at (0,0) {med};
  \node (gfix) at (4,2) {gfix};
  \node (nfix) at (-4,2) {nfix};
  \draw[->] (ready) to (med);
  \draw[->] (premed) to (med);
  \draw[->] (ready) to (gfix);
  \draw[->] (ready) to (nfix);
  \draw[->] (med.north) to (gfix);
  \draw[->] (med.north) to (nfix);
  \draw[->] (dependent.south) to (gfix);
  \draw[->] (dependent.south) to (nfix);
\end{tikzpicture}

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