An unintended trend in medical ed

By Loren Deutsch

There’s an expectation that when students are accepted into medical school, they will naturally know how to learn and achieve. This expectation is often reinforced by faculty, families, and students themselves, making underachievement in medical school particularly debilitating. Added to this is the pressure students feel when trying to change an unproductive learning cycle while in the midst of their coursework.

Aside from contributing to the trajectory of their career, academic performance often plays an important role in a medical student’s identity. For some, it is a contributing factor to a “deficit accounting” paradox that can be found in their study habits. The cliche of borrowing from Peter to pay Paul becomes a truism when overwhelmed students spend time studying to catch up on previous coursework, while failing to stay organized and consistent with current coursework. They find themselves falling farther behind and deficit accounting quickly becomes unsustainable.

As educators we have noticed a definite trend in medical education, when students struggle academically it often can relate to an over-reliance on rote memorization. Students frequently mistake memorization of lists and definitions for conceptual learning. We see this in particularly stark ways as students prepare for high stakes exams, such as the USMLE Step 1. As the first major board exam in medical school, not only does it assess students’ abilities to consolidate and apply the first two years of information from medical school using case vignettes. Furthermore, it underscores the high stakes exam experience because their Step 1 scores will contribute to their placement in residency.

Why memorizing falls short in medical school

Rote memorization is a point of entry for learning and if used exclusively, it fails to engage the higher order thinking necessary to ensure comprehension, synthesis, and application. In the book Why Don’t Students Like School?, cognitive scientist Daniel Willingham does a great job explaining the science behind memorizing or “list learning” and contextualized knowledge. In an attempt to address knowledge gaps, students frequently amass study resources, including flash cards of facts that they often have difficulty integrating in a meaningful way because they lack context.

It is insufficient in medical school to memorize because there are too many details without an organizing framework, so students who rely on it to deepen their fund of knowledge often fall short. Therefore, when designing a study plan it is important to develop a conceptual understanding of new information before trying to memorize or learn specific details.

What actually works

Changing learning and study habits requires changing habits of mind. Instead of trying to quickly change all study habits, consider making incremental adjustments, little by little. One study technique is to connect the details while reading or using flash cards. The approach is malleable and be tailored to fit individual student needs.

As an example, when medical students learn about pharmacology, they are often in their second year of school and do not have the benefit of clerkship experience to draw upon when conceptualizing myriad drug lists they need to understand. Key drug information includes classification, indication, mechanism of action, and toxicity, among other details. In using flashcards, students often try to memorize individual drugs by incorporating one or all of this drug information onto a single flashcard. As they quickly see, drugs have different classifications and it can take hours to wade through 50 to 100 different drugs within one classification. Multiplying this by the number of drugs in a given classification quickly becomes daunting unless the connections are meaningful and not just a list of words.

One of the ways to make these connections meaningful is to develop a more integrated understanding about pharmacology. By starting with anatomy and physiology, and gradually adding pathology, and pharmacology, students can arrive at a more conceptual understanding of treatment options. Say you are studying endocrinology, specifically the pituitary gland. Consider the following strategy:

Open up an anatomy resource. Essential Anatomy is one of many resources that would be useful for this.

1. Identify the pituitary gland (structure and function)
2. Verify that you can identify neighboring structures along with their functions before proceeding. Consider verbally articulating the physiologic process of that system. The first few times you do this, you may need to consult a resource – consider BRS Physiology for quick reference, if necessary.
3. Depending on the pathology, you should be able to identify the disease process, and treatment options, including drug classification. Within the classification, identify the specific mechanism of action or the molecular targets to which a drug binds, etc.

Trying to memorize these details is virtually meaningless if learned as a string of words such as “mechanism of action” or “toxicity” and not within a conceptual framework. However, when we contextualize this information in terms of gross anatomy and normal physiology, we then lay the groundwork for a more integrated understanding to a specific pathology and its pharmacologic treatment. These details are critical to build a conceptual understanding.

At LAS, we often meet with medical students who have relied heavily on their memorization skills to learn new information. They cram for a test and do well, so they think this is a preferred study habit. Unfortunately, memorization doesn’t equate to meaningful connections between discrete pieces of information. That process takes time and cramming is inadequate because the volume of information too great in the time available.

Conclusion

While students often enter medical school with the ability to memorize effectively, however this is insufficient because it doesn’t equate to comprehension or higher order thinking. Therefore,when medical schools and residency programs require remediation of failed exams it is critical to keep in mind the very learning process that lead to a failed exam: trying to memorize a lot of information in a small amount of time, for one exam. When students remediate a failed exam using the same techniques that failed them in the first place, they haven’t necessarily learned how to learn more effectively. They also haven’t necessarily learned enough about the information at hand, something that has implications for their fund of knowledge.

At LAS we provide academic support to medical students and residents, in part by helping them develop a personal road map for learning and achieving. We modify cycles of underachievement, often characterized by rushed remediation, to cultivate the problem solving and decision making skills necessary for physicianship. This is predicated on a deeper understanding for the science and general principles found in medical education, as opposed to superficially recognizing new material.