Philosophical musings on tests in medical school and beyond


Category : Medical Rants

Yesterday I read the latest “On Being A Doctor” in the Annals of Internal Medicine.  The story – Murky Water – tells the story of a classmate who committed suicide after failing step 1 by 1 question.  Over the last 12 hours I have pondered this story as well as an article in the same issue titled The MCAT’s Restrictive Effect on the Minority Physician Pipeline: A Legal Perspective.

What do standardized tests tell us?  In college

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, as a psychology major I took a course in Psychometrics.  I understand the principles behind designing tests that produce bell shaped curves.

Test scores measure retention of information and the ability to use that information to understand and answer questions.  We all know colleagues who are particularly good at taking such tests (even when they do not know the material that well) and other colleagues who consistently underperform on those tests.

Clinician educators see students who do very well during the first two years of medical school and on step 1, but who struggle during clinical rotations.  We also see “bottom quartile” students who blossom during their clinical years.

As I have pondered the value of these tests.  What are the dimensions of master physicians?  The Closler initiative (moving us closer to Osler) lists 4 large dimensions:

  1. Connecting with patients
  2. Clinical reasoning
  3. Passion in the medical profession
  4. Lifelong learning in clinical excellence

Of all these perhaps #4 could be tested.  But even then we have a disconnect.  What is the goal of our education?  We should understand physiologic and pathophysiologic processes; we should do likewise for relevant anatomy; we should understand laboratory testing and the use of imaging; we should understand our pharmacological options as well as other therapeutic options and be able to weight the risks and benefits of each.

The key word here is understanding.  As an educator

, too often learners can regurgitate lists of potential diagnoses, but they lack a true understanding necessary for clinical reasoning and decision making.  Our education which unfortunately is dominated by the tests and subsequent test scores too often implicitly devalues learning to understand when learning to do well on the test is the goal.

These are not original thoughts.  But they are thoughts too often ignored in medical education.  We say we want to produce physicians who fit the Closler initiative but then we talk about Step 1, 2, and 3 incessantly.  We judge residency applications partly on these scores.  We judge our residencies by pass rates on specialty boards.

I suppose tests are necessary evils.  But I wonder about the unintended consequences of psychometrically pure tests.  We produce some great physicians

, but we could do better.  We can never reform the curriculum when “the test” represents a high stakes hurdle.  We need a different approach to evaluation.  We all really know that, but we seem helpless to address the problem.

But on each rotation I work hard to help the students and residents understand what we are doing rather than just memorizing an algorithmic approach.  The learners seem to like this approach and sadly find it refreshingly different.  And that saddens me.

The story that influenced this post haunts me.  How can a test lead to such a tragic end?  Yet I understand the implications of these tests.  I see it in our students, our residents and practicing physicians.  And I do not like it.

Comments (3)

Test can take on an overwhelming presence in dealing with patients. After a health scare a doctor told me he should not speak to me due to the results of a test. Funny, I was holding my wife’s hand keeping her from exploding at his comments. He also commented I should not be let out of the house alone.

Young doctors often are enamored with test and data. One doctor, after a series of insults, told me seeing patients only slowed his process. Everything he needed to know was in the test results and paperwork.

Medicine is about people and medical people need to look and listen to their patients.

Steve Lucas

Steve Lucas- I think you might have missed the point of the article…

The story that influenced this post haunts me.

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