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.”
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.
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.”
The entire way medical professionals get educated is flawed:
1) Requiring a Bachelors first. That is using 4 years of time and over a $100K to educate students with information that isn’t specifically relevant to their vocational field
2) Medical study boils down to memorizing a vast amount of information. Given human long term memory retention, significant portions of that knowledge will be forgotten. Additionally, the internet allows the specifics of an idea to be instantly obtained
3) Learning critical thinking requires practice. Engineers spend 4 years learning critical thinking and how to break down and solve problems
4) The limited number of medical schools place a hard cap on people entering the field (20K a year)
5) The cost of medical school discourages qualified applicants and puts doctors in significant debt.
Basically the current system is radically driving up healthcare costs and simultaneously producing questionable results.
We ran a quick experiment to see if lecture or a related Sketchy video was more effective in teaching students content. Both groups performed similarly on a follow-up multiple choice question test, with a slight non-significant increase in the lecture group. They took the same amount of time to deliver. It’s surprising that so few studies have tested the efficacy of these online resources. It’s just assumed that they teach content better. It certainly doesn’t breed a positive relationship between students and faculty or teach students how to communicate with fellow professionals. I think we are teaching a generation of disconnected physicians who can only think in the context of a multiple choice question.
The article largely misses the point. Medical education in the first years is about being efficient with time. If the curricula facilitates efficient learning, then it will be attended. If not, then students will find better means.
Students doing poorly often have distractions, commute, or do not take tests well. Some learn in ways different than medical schools teach.
After a few years in a clinical presentation model with small groups and guided instruction and clinical skills emphasis – the medical education model is so wrong for preparation for a medical career. But sadly this is an expensive model with clinician faculty experience and time required. Clinical presentation provides a framework to attach basic science and other learning.
Chest pain week involves physiology, biochemistry, anatomy, and clinical skills relative to the causes of chest pain – heart, lungs, GI, mental, and more. EKG and simulations and small groups integrate the learning.
…and yet this same people with complain about NP programs offering lectures(video/audio/PP) ONLINE. It’s time we embrace technology to help enhance learning.
Why aren’t professors looking at themselves to see how they can improve their lectures to attract more students. Why would I go to a 2h lecture when I could learn the material in 30m in my PJs at home??? Especially when they have BETTER explanations, more relevant to what we need to know, and memorable.
Wow, How things have changed. My experience with newer Doc’s is either didn’t learn how to take a history and how to do an exam or can’t remember what was on the video they looked at to take the test. Not sure how the new change has impacted on patient results.
Probably very little. The education you get in the first 2 years of medical school does not always correlate with what doctors are expected to learn. Most people say they learned how to be a doctor during residency, not medical school.
Taking a history isnt tested on step 1 or at least not with enough volume to make it worth your time. If you dont get certain scores on the steps many desirable residencies pay your application no attention and that is a fact. I have been on application review committees and if you didnt have a 240, you arent even considered. Your application never even gets a glance. So, until that changes, what incentive is there to learn how to do a good history or physical? You only have so many hours in a day. Theres no such thing as a free lunch.
Medical school is obsolete, at least the first two years. Information is freely available in the age of the internet. Anyone motivated can learn the material and passed Step 1. Medical school is just another expensive hoop jump.
We stated. It is just part of the hazing process
This hit the nail on the head. Listening to a professor talk about his own research for HOURS and testing us on his own research that wasn’t applicable was a waste of time. I found BnB during dedicated and it was how I imagined med school would be taught. It was well organized and followed a logical pattern. The med school I attend seems to pick topics out of a hat and just go with it with no logical flow.
I cannot believe that I heard this from a medical student. If we don’t do research, I wonder how we can find the medication to treat diseases. Medical don’t just drop into a physician’s desk. I am glad that I choose MD/PhD track and appreciate the importance of research.
Absolutely true even in my Country India. Before I put any puzzle smart student starts answer with You Tube and other online reference. At the same time digital media has eased Embryology, Anatomy like subjects!!!
I agree with ya 100%, Chunnilal.
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