T

he 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.

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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.”

SketchyMedical produces visual memory aids with elaborate illustrations, like this one of the major drugs targeting the sympathetic nervous system. Stephen Wang at SketchyMedical

The medical tour guides

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.

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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.

“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.”

Ryan Carlson, third-year M.D.-Ph.D. student at the University of Washington

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.

The old players react

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 — with new drugs, guidelines, and practices — 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.”

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  • in the dark ages before computers, we dutifully made our multicolored notes with our 4 color pens, in class from which we studied at home for an exam to come later from that material. We were not concerned about any distant exam but expected that preparation along the way (including reading about the patients we saw along the way) would prepare us to pass that exam. These notes we made were our “powerpoints”. Now students don’t have to go to lecture to make powerpoints but dialogue with professors to make the information pertinent was also important. We have to hope that the next generation of docs will be curious and explore and continue to learn after the last exam is done. Perhaps the infamous Step 1 needs to be retooled to address “what a reasonable physician should be expected to know and use in his/her practice of medicine” rather than a trove of info to be learned for an exam and promptly forgotten, which could be looked up in smartphone app. (I use UpToDate).

  • @PGY2:

    I appreciate your reply – but you misunderstood. I share your concerns that with the expanding universe of medical knowledge, no way can one know every thing. Tis development has triggered efforts of medical version of Siri for doctors (in the development of which I am involved in). For it is clear that doctors will not and should not act based on memorized knowledge. BUT: This migration of medical knowledge to your smartphone is precisely the reason why medical schools MUST teach rigorous reasoning in terms of fundamental pathophysiological principles so that patient individuality can be taken into account as a whole. Such reasoning cannot be replaced by AI. But the very process of acquiring reasoning and integrative skills requires memorization of a basic set of facts – not JUST the oft romanticized “problem solving skills”. There is no way around memorization of some atomic principles and facts. They cannot be made up, neither reasoned up nor looked up. I have taught for a decade at Harvard Medical School and never seen the top students rebel against rot memorization. The act of finding personal ways for efficient memorization is enlightening if you are motivated. You mind merges with the medical facts and become one. This is the basis for being a good doc. Then on top, you can look up dosages for specific drugs on your smartphone – no need to memorize these. And I have trained hundreds of medics in the military. No way we will give up memorization of basic procedures and drills only because the fad of complaining about memorization. Emergency situations are too serious.

  • Students have used for First Aid and other resources for at least 20+ years
    Since the dawn of the internet, there have been other ways to learn material
    Lots of it is nonsense forgotten the day after the exams anyway and not relevant. They would be better off having medical lecture trainers..not PhD’s/MD’s doing researcch giving lectures

  • This is nothing new. I graduated from medical school in 1990 and after the first semester of first year I rarely went to a lecture. I could read/learn 3x as much in the library as I could listening to someone drone on and on.

  • Perhaps these successful students have simply learned how they learn best. Personally I sat in lecture 8-4 my first year. Then I learned that I am a terrible auditory learner. By skipping lecture I reduced a format that was not effective for me and had more time to read, annotate, color, and diagram the syllabus and texts. Some students do well with passive auditory learning but others do better with sketches, videos, diagramming and coloring, flash cards, or group studying. By the time students get to medical school most know how they learn best – let them implement it.

  • Medical school lecturers believe they are the most important person in a room of 150+ medical students, and they deliver information accordingly. I stopped going to lecture because I didn’t (and still don’t) care about anyone’s research on invertebrate nervous systems or what anyone’s cat did this morning. Any outcry you hear over this attendance issue is because the old guard of medicine is upset they’ll have to find a new way to stroke their egos.

  • Lot of topics mixed together for little reason. Medical Students worry about passing but most will as prior indication of test taking the best predictor. Why go when it is online 24/7. That is the reason for not attending.
    MD/Phd students are a different breed. Their schedule is much different.

  • Could this be why most MD’s these days seem to lack curiosity and be quite lazy? There don’t seem to be any diagnosticians anymore.

    • Tell us more about what, in your personal experience, makes you think “most MD’s these days” are lazy and lack curiosity.

      While you’re at it, tell us more about how YOU personally are more curious and less lazy than “most MD’s”. I’ll wait.

    • The reason MDs seem burnt out these days has more to do with mounting pressure to see more and more patients per day, dealing with insurance companies who do everything they can to not pay for treatments, and ridiculous amounts of paperwork

  • Clever use of the tumbleweed in the graphic above: abandoned lecture hall ‘town’ or students out rolling through approaches to find one that works for each? But in the end, the med student has to pass both the ‘local exams’ & the board exams later on.

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