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February 1, 2006

My Current Thinking on Medical School Performance

The central question every new medical student wants to know is "I know the exams are the measure by which I will be judged when it's time to apply for residencies. How should I prepare for exams?" It's difficult to answer this question when you're on the inside.After the first set of exams the good students will lie and say they could have done better. They know how hard they studied and don't want to be dragged down by poorer students seeking assistance. The students who find themselves struggling will lie and say it wasn't that bad. They know it's a dog-eat-dog world so they don't want to show any sign of weakness.

What really pisses me off is the professors. The professors will lie and tell you to learn the concepts, the big picture. This, as far as I can tell, came out of Bloom's Taxonomy of Educational Objectives, which identified six categories of testing, ranging from basic cognitive function, tested by knowledge questions that ask students to name, identify, or define things, to sixth level evaluation questions that ask students to appraise, judge, or critique. In observing that most test questions are knowledge or comprehension questions (levels one and two) most educators have assumed that these are easy questions to write, and therefore they are weak questions, and therefore such questions are beneath good teachers and students. Now it's easy to get confused about what the different levels of questions are, even if you have a comprehensive database of samples mined from every available internet source and have read both authorities on the subject. So virtually every professor just writes their damn tests and congratulate themselves when they finish with a stiff drink. "Bloom's taxsha wha? Ish that a ... Do 'hey shtuff deer?" At least, that's what I would do.

However, on close inspection, like when taking a test, if you've studied Bloom, you know what kind of question you're being asked. Because it is clearly relevant to your situation, which is figuring out the right answer. That's what I did to prepare for the MCAT, and it has stuck with me (I admittedly review now and again).

So here's the deal. The professors ask 80% to 90% knowledge and comprehension questions. And let's face it, you're in medical school. We know you can evaluate things and accomplish all those other higher level tasks. If for no other reason than the MCAT does test those higher order abilities. So is it all that bad that that you're supposed to know some actual facts? Who cares if you dump most of it over time. That's what happens in the real world. Dr Thomas Lee, an editor of the New England Journal of Medicine, recently wrote a Perspective article in in which he opined that doctors now don't need to know things. They need to learn how to learn. Preceding this observation was an article by the director and deputy director of the National Library of Medicine, who clearly laid out their expectation that the data rate will only continue to increase. These are the people that make funding decisions. That's what they're thinking. Pump the structures, doses, procedures into your head, and then use them. The amount of information required to diagnose and treat diseases today, when we know there are a zillion drug interactions and genetic disease and protein conformations, is stupendous. Learn it, use it. If it falls out after you're done you didn't use it much so it wasn't all that important. Hey, no use in crying over spilled milk.

Problem is the professors are ashamed to admit it. They still think they're supposed to be teaching and testing those higher order functions. So they lie to their students and say you don't need to recite the difference, per se, between heparin and heparan sulfate. We'll give you the structures on the test. Liar. At 1 am when they're writing the tests, they're in no condition to be coming up with deep questions that can actually test your ability to synthesize information.

You can use all that higher order problem-solving stuff later. Learn how to gorge on facts: structures, formulas, image patterns, diseases and their mechanisms. Actually, you'll use those higher order skills to organize the information and make connections so you can remember the facts more efficiently (only so much space in that noggin). But the central problem is learn the facts.

Flashcards are good for this. But don't buy them, except maybe for anatomy and histology, which are incredibly complex visually. Outside visually detailed subjects, make your own flashcards. Use white 3x5 cards. The ones with no lines on either side. Identify the facts you need to know. Use the learning objectives. Bottom line for the exam: fill your head with the facts.

I don't think that professors lie maliciously. I think they very, very often interpret the social context of student encounters (during lecture, before or after lecture, during office hours, chance meeting in the hall) in such a way that they believe their role is to 1) assure the weaker students that things will be okay, and 2) affirm their collegiality with the better students. I can understand why the students commit their deceits amongst each other, they're being ranked. But what motivation does a professor have to violate their basic responsibility to provide the students the objective information they need to maximize their performance? If the tests don't matter, then why test? Why not go to the Yale system?

Posted by Niels Olson at February 1, 2006 11:00 AM

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