In Med School, It Can Pay to Skip Class. What’s Wonky Here?

(Bloomberg Opinion) -- First comes “back to school,” and then, for some, it’s back to playing hooky. Disturbingly, that would include many future doctors. According to one recent survey, a quarter of medical school students almost never attend lectures.

Many are skipping class to study for a standardized exam called the Step 1, according to a story in the medical news website STAT. Scores can stifle or catapult careers because residency programs use them as a main selection criterion. In the past, it only mattered whether students passed or failed this test, and their opportunities after graduation depended more on their grades in medical school. But that’s now reversed, with med school classes being graded with a pass-fail, and the scores on the test determining career trajectories.

Students interviewed for the STAT story said there was a disconnect between what medical schools teach and what they need to know to do well on this exam. It may benefit students to focus on the test, but does it benefit patients? What should medical students be learning to make them competent doctors?

That is changing with technology and a rapidly expanding body of medical knowledge, said Isaac Kohane, a researcher and teacher at Harvard Medical School. He and Richard Schwartzstein, director of education scholarship at Harvard, agreed that memorization is becoming less important. What matters more than ever is critical thinking, understanding concepts and the mindset to keep learning.

And yet, according to the STAT interviews, Step 1 is so heavy on memorization that much of the studying consists of using online systems for memory tricks, used to call up medical terminology, obscure diseases, and other things easily looked up.

Kohane said at Harvard students don’t choose between lectures and memory aids. In an effort to keep up with times, Harvard has done away with most traditional lectures, letting students learn the basic material on their own and then requiring them to participate in discussion sessions. The idea, he said, is to rely on the students’ integrity to learn the required material. Then the professors can use their experience to focus that knowledge, he said, and guide the students in how to apply it in the real world.

Students also get time to study for Step 1, which he told me he considers a sort of hazing ritual. Another is the requirements you have to have taken calculus and physics as an undergraduate. “I happen to love calculus and physics,” he said, “but I’d say for 99.9 percent of doctors it’s a filter on the kind of students they want to attract to medical school.”

From the perspective of potential patients, filters are critical — and it’s critical that they sort out the most promising students. Why would a memorization-heavy test be so critical at a time when memorization has never been less important? Schwartzstein said that, indeed, medical schools could serve as a better filter. He said once in medical school, between 97 and 98 percent of students graduate — and he is not convinced that all are cut out to be good doctors.

“I believe based on my own experiences and what I hear from colleagues around the country is there are people who graduate medical school who probably shouldn’t have,” he said.

And what happened to grades? Might they help students rethink career plans before they get too invested and perhaps too far in debt? Doing away with grades, he said, was based on an idea from educational theory — that notion some people don’t learn as well in a competitive, performance-based situation. That seems great for elementary school, but medical school? They’re going to be judged on their performance eventually. Schwartzstein said that he sees an upside to grades, too. They’re a more complete source of data on student performance than standardized test scores, and the threat of a bad grade may be a better motivator for some students than friendly suggestions are.

The facts and figures that doctors need to know change all the time, but it’s likely doctors will need wisdom, good judgment, adaptability and humility for some time to come. Whatever medical schools can do to impart these virtues — traditional lectures or discussion classes — will benefit us all. As for the students falling short … well, medical school professors may be reluctant to “abandon” students, just as they don’t give up on patients who fail to follow directions. But Schwartzstein agreed that professors owe a duty to the public to guide medical hopefuls who aren’t doing well into other professions.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Faye Flam is a Bloomberg Opinion columnist. She has written for the Economist, the New York Times, the Washington Post, Psychology Today, Science and other publications. She has a degree in geophysics from the California Institute of Technology.

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