Medical students are skipping class in droves — and making lectures increasingly obsolete
Future doctors are skipping class in droves and making lectures increasingly obsolete
Harvard Medical School’s curriculum changed to meet new demands in 2015.
By Orly Nadell Farber, STAT
The future doctors of America cut class. Not to gossip in the bathroom or flirt behind the bleachers. They skip to learn — at twice the speed.
Some medical students follow along with class remotely, watching sped-up recordings of their professors at home, in their pajamas. Others rarely tune in. At one school, attendance is so bad that a Nobel laureate recently lectured to mostly empty seats.
Nationally, nearly one-quarter of second-year medical students reported last year that they “almost never’’ attended class during their first two, preclinical years, a 5 percent increase from 2015.
The AWOL students highlight increasing dissatisfaction and anxiety that there’s a mismatch between what they’re taught in class during those years and what they’re expected to know — or how they’re tested — on national licensing exams. Despite paying nearly $60,000 a year in tuition, medical students are turning to unsanctioned online resources to prepare for Step 1, the make-or-break test typically taken at the end of the preclinical years.
These self-guided med students are akin to a group of American tourists wandering through Tokyo without a map. Like a tour guide hired on the street, the online learning tools — including memory aids, videos, and online quizzes — can enhance the educational journey, or send the students down a dead end.
Lawrence Wang, a third-year M.D.-Ph.D. student at the University of California, San Diego, and the National Institutes of Health, said he relied heavily on these resources during his first two years of medical school.
“There were times that I didn’t go to a single class, and then I’d get to the actual exam and it would be my first time seeing the professor,’’ he said. “Especially, when Step was coming up, I pretty much completely focused on studying outside materials.’’
Wang isn’t alone. According to 2017 data from the Association for American Medical Colleges, 1 in 4 preclinical students watches educational videos — like those on YouTube — on a daily basis. And according to two video developers, tens of thousands of medical students subscribe to their products — one of which costs $250 for two years, the other $370 for one year.
Leaders in medical education have begun to scramble. Some medical schools, like Harvard, have done away with lectures for the most part. Instead of spending hours in an auditorium, Harvard students learn the course content at home and then apply the knowledge in mandatory small group sessions.
Other institutions, like Johns Hopkins, are moving in the same direction, but have yet to make a full switch. Hopkins cut down on lectures and boosted sessions that require active student participation. Preclinical lecture attendance hovers around 30 to 40 percent, according to Dr. Nancy Hueppchen, associate dean for curriculum.
For many students, she said, licensing exam prep begins on day one of medical school: “They have this parallel curriculum going along with what we’re teaching them.’’
Step 1, an eight-hour multiple choice test, is a big deal. Performance on the exam, though it’s taken before most students even begin training in a hospital, heavily influences which medical specialties they can eventually pursue after school and at what hospitals they can pursue them.
With medical schools grading pass-fail, the Step 1 score is an increasingly significant piece of information that’s used to sort through residency applications, Hueppchen said. When she took the exam, it was only used as a pass-fail test. Today, residency programs rely on the score more heavily; students and faculty suspect that it’s used as a cutoff for making admissions decisions.
Ryan Carlson, a third-year M.D.-Ph.D. student at the University of Washington, said that his school focused on teaching “what they thought was important for a physician to know.’’ But medical students have to know more than what is relevant to a practicing clinician to succeed on Step. The exam focuses on rare diseases and other minutiae, said Carlson, who now tutors for the test.
Hueppchen acknowledged that students at Hopkins and elsewhere “express some distrust that they’re getting everything they need — or that we’re being meticulous in pointing out what they need — to study for and excel on the Step 1 exam.’’
***
That distrust has spawned a cottage industry of online study aids. Most are a far cry from your high school SAT prep course.
SketchyMedical is one of the most popular guides. The company, built in 2013 by three then-medical students at the University of California, Irvine, produces visual memory aids with elaborate illustrations to help students learn and retain the voluminous material they’re expected to know.
Dr. Andrew Berg and his co-founders, Drs. Saud Siddiqui and Bryan Lemieux, started sketching pictures and pairing them with stories while taking microbiology in their second year of medical school.
“We were just bombarded with different names of bacteria, viruses, and fungi, and we were having a tough time keeping them all straight,’’ he said.
The sketches helped them, and now other students are using them, too.
Imagine it’s test day and a med student is asked which drug she would use to treat a patient’s postoperative gastrointestinal blockage. The student closes her eyes and mentally enters the world of “Acetyl-Cola,’’ a bustling port town that’s depicted in one of SketchyMedical’s cartoons. Outside a storefront, the student finds construction workers, motorcyclists wearing brain-shaped helmets, piles of dripping-wet fish, and a man sporting an adrenal gland-shaped beanie.
A colon-shaped mixing truck pouring out cement is an unfortunate, but effective, symbol for defecation, and a worker wearing a name tag reading “Beth’’ and drinking a cola reminds the student of the drug bethanechol, given to treat intestinal obstructions.
The illustrations are turned into narrated videos, which teach drug names and their mechanisms and side effects. SketchyMedical has also produced videos on microbiology and pathology.
Berg compares the work of Sketchy to hieroglyphics in ancient Egypt. But for many, Sketchy evokes a different technique used a thousand years later in ancient Greece: method of loci, also called a memory palace or journey.
Memory palaces are typically imagined spaces in which a person can store information like a string of numbers or a series of words. Each piece of information is placed somewhere inside the palace. When the palace builder wants to recall an item, she can take a mental stroll through the space to retrieve it. This technique famously enabled Cicero, the Roman statesman and philosopher, to commit his speeches to memory.
“We accidentally stumbled upon these visual learning techniques, but now looking back we see there’s a lot of evidence supporting visual learning,’’ Berg said.
SketchyMedical is not the only extracurricular resource students rely on. An entire industry cropped up in the last few years, marketing videos and self-quizzing features to preclinical students. Dr. Jason Ryan, the creator of Boards and Beyond, is a name (and voice) familiar to medical students across the country.
Ryan, a faculty member at University of Connecticut School of Medicine, creates explanatory videos that track along with the content in First Aid, a Step preparatory book that Ryan said is more like “an encyclopedia of terms’’ than a real study aid. Ask any medical student if they use First Aid, and they’ll point you to their heavily annotated, tattered copy.
While both Ryan and Berg consider their products supplements to regular medical education, many students view them as necessary investments for success. Choosing which ones to use can be a challenge, however.
“That was the biggest learning curve of med school — it wasn’t so much how do I do well in it, it was, how do I use all these crazy resources that are being marketed to me to best meet my goal of passing Step,’’ Carlson said.
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This expanding corner of the medical education industry is both a product of a new attitude among students — born from anxiety surrounding exam prep — and a disrupter of the traditional classroom education. Med schools now have to think more creatively about how they train their future doctors, Berg said.
In 2015, Harvard Medical School revamped its curriculum for the first two years to enable clinical exposure and boost class attendance with a flipped-classroom model: Students learn the content at home, and then apply it during in-class exercises. Dr. Richard Schwartzstein, director of education scholarship, said the program now emphasizes problem-solving and critical thinking — skills seen as essential to practicing medicine — instead of factual recall.
But while medical schools are de-emphasizing pure memorization, the national licensing exams have yet to reconsider, he acknowledged. Still, Schwartzstein is not a huge fan of external resources, citing their focus on memorization and pattern recognition as major weaknesses.
“You don’t have to actually teach pattern recognition,’’ he said. “We all are born with the capability of recognizing pattern.’’ He advises students to stick to Harvard-developed videos and their recommended readings. Like many medical schools, Harvard gives students a dedicated study period — six to eight weeks without coursework — to “prepare in whatever way they deem most appropriate to take the boards,’’ he said.
Hueppchen said that the outside resources “may have value in day-to-day studying, they may have value in studying for Step 1,’’ but Hopkins has not vetted them so it doesn’t recommend them to students either.
The National Board of Medical Examiners, which works with state medical boards to set the minimum standards for medical licensing and administers the Step exam, also doesn’t endorse these products — or their use as hard lines for residency admissions, said Dr. Michael Barone, vice president of licensure programs. The group “is aware of some secondary uses of scores,’’ he said, but the test’s primary purpose is to report licensure alone.
So long as Step still requires intensive rote memorization, companies like SketchyMedical and Boards and Beyond will likely remain in business.
Both Berg and Ryan agree that physicians no longer need to memorize as much as they did in the past. Ryan’s grandmother was one of the first female physicians to graduate from her medical school in the 1940s. Back then, he said, she had to remember everything. “If she had to go to a book every time she saw a patient, she’d never be able to work through the day.’’
Today, there’s much more to know, and medicine is evolving so rapidly that physicians can’t possibly remember it all. Instead, they look information up on their cellphones, using a variety of apps on the clinic floors. But preclinical students still need to commit board-tested material to memory, a task often compared to drinking from a firehose.
Needing to memorize for boards and learn in parallel for their institutions is the breeding ground for anxiety that Hueppchen said “has truly detracted from the joy of learning.’’ It has even detracted from the joy of teaching, she added.
Berg said he tries to bring joy to memorization: “I think that what I hope to contribute the most is making studying more fun.’’
Orly Nadell Farber is a reporting intern at STAT, where a version of this article first appeared.
Sunday, August 19, 2018
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Aug 9, 2018
Earlier this year the Fordham Institute wrote about the challenge of the gifted gap in our nation’s schools. Put simply, gifted students from disadvantaged backgrounds too often are not identified as gifted, which causes them to lose out on access to a variety of gifted-and-talented programs at their local schools that could accelerate their development and social and economic opportunities.
The report’s authors offer seemingly three solid recommendations toward this end—universal screening for gifted students; identification of gifted students within each school, not just district-wide; and active efforts to counter bias.
Those make sense if we assume gifted programs are a good idea. But in a day and age where we can move past our factory-model schools and personalize learning for all students, such that students can move at their own pace and not grow bored or disengaged and can dive deep into areas of passion, should schools be in the business of placing labels on students designed to sort them?
Count me as unconvinced.
In 2010, a fifth-grade student named Jack (his name is disguised) started the year at the bottom of his class in math at Santa Rita Elementary School in the Los Altos School District in California. I visited the class several times during the year. Jack had struggled to keep up in math and grew to consider himself one of those kids who would just never quite ‘‘get it.’’ In a typical school, he would have been tracked and placed in the bottom math group—and he certainly would not have been considered a “gifted” student. That would have meant that he would not have taken Algebra until high school, which would have negatively impacted his college and career choices.
But Jack’s story took a less familiar turn. His school transformed his class into a “blended-learning” environment to personalize the learning. After 70 days of using Khan Academy’s online math tutorials and exercises for a portion of his math three to four days a week, rather than remaining tracked in the bottom math group, Jack rose to become one of the top four students in his class. He was working on material well above grade level.
The reality was that Jack had just missed some mathematical concepts in much earlier grades that continued to haunt him. When he had the opportunity to revisit those concepts and master them, several of his misunderstandings disappeared. Jack started to soar.
The traditional system would never have been able to reach Jack. Its treatment of students like him amount to educational malpractice, even though we do not call it so. Labeling other kids as gifted would have damaged Jack’s ability to make progress, both because of his self-perception as well as others’ perception of him.
As Jack’s performance changed, Jack’s self-perception changed as well. I am also fairly certain that Jack’s performance, as well as that of his classmates, will remain uneven, with bursts of accelerated progress and periods of struggle.
Closer to home in Lexington, Mass., where I live, over coffee a parent told me that his daughter in the eighth grade was anguishing over whether to take regular or honors math next year in high school. The stress over the decision was intense, he said. As stress like this builds, he told me that many parents were considering taking their students out of the public school system. I couldn’t believe this was all just over what math class a 14-year-old should take. Why did she have to choose, label herself, and place herself on a track with no flexibility?
If Lexington Public Schools moved to a mastery-based system, one in which students progress as they master material, not based on an arbitrary measure of time, and utilized blended learning to personalize for each student, she could just take “math.” Lexington High School could maintain a minimum pace at which she had to move and then she and the school could see how far and deep she could move in mathematics. In the course of taking it, she might surprise herself—and avoid closing off a door too early. If colleges really needed a label later to evaluate her, the school could retroactively provide one based on her actual progress.
To be clear, I’m not advocating for saying everyone is above average and giving medals for participation. A mastery-based system is more rigorous than our current one because students would only make progress by demonstrating mastery of learning. Rewards would only follow true mastery. But I’m also unconvinced applying labels makes sense when, in a personalized system, those same labels could be wrong and outdated on any given day. Labeling risks shortchanging a lot of students. And society loses, as we miss out on fully developing future human capital.
If we give students like Jack the stretch opportunities they need to soar without labeling them gifted—or avoid incorrectly labeling them and taking away those same opportunities—don’t we create a better system?
The more important principle is to make sure we do not shortchange students based on their race, income, or gender. And if we start judging everyone based on mastery, I think our chances are a lot higher of fixing that problem than if we continue to obsess about labels.
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