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.

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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.

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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  • Why do so many students of elite US medical colleges skip classes?

    If they were other students, school-going or even from arts/science/commerce colleges, we would possibly consider that they need to be ‘engaged’ better by making the lectures more interesting. But these are first- and second-year students who get selected in these top medical schools (Harvard or Johns Hopkins, and several others) after a lot of effort, and are paying high fees of USD 60,000 or so. Do they believe that the lecture system has become obsolete, or needs change? Majority of them say NO. However, the data submitted in response to a Questionnaire circulated to the Medical School Year Two students during the years 2015, 2016 and 2017, published by the Association of American Medical Colleges (AAMC) in March 2018, presents some revealing details. On one hand, it shows that the majority of the active second-year students of dozens of medical schools have no complaints about the lectures, and express satisfaction about the quality of the medical education and even of the lectures. On the other hand, a majority of these students do not attend these lectures, not because they are whiling away their time. Rather, they devote a lot of time preparing themselves for the STEP 1 in an organized manner by attending online video lectures, YouTube lectures or virtual pre-clerkship courses and, studying the basic information from Wikipedia, etc.

    Why? because they want to learn at a faster rate, and also more on the peripheral knowledge beyond that imparted in the formal lectures. They have learnt that for doing well in STEP 1, they need to learn more about topics which are knowledge-heavy and require a good familiarity with the vastly specialized terminology used in topics related to say microbiology or cell biology, etc. Listening once about a topic or entity in a lecture or even revising it once may not be enough, so they look for alternative routes to assimilate as much knowledge as they can, even perhaps by discussing amongst themselves. The late Prof. H.W. Kroto, Nobel Laureate in Chemistry, considered the originator of the popular twin subjects of nanoscience and nanotechnology, and an excellent teacher himself stated once that perhaps half of his own learning at University came through interactions with his fellow-students, the other half by learning from textbooks and lectures by his teachers. In fact, in 2014, he advised that there is no harm if some useful information can be memorized!

    Should this lecture-skipping by students make Harvard Medical School abandon the formal lecture system, even if for a flipped-class model? Definitely a face-to-face formal lecture by an expert has value, otherwise why do people go to hear TED talks? Then what do we say about the students in these medical schools who claim they didn’t attend a single lecture, even if they trust that the lectures alone will not suffice. Are they not going to the extreme of reposing their trust solely in the ‘memory palaces’?

    One can discount the skipping-lectures-largely habit for a rare species of ultra-bright student whose grasp is enormously quick. There have been instances to prove that a super-intelligent hard working student scored top honors even though he skipped most of the formal lectures, that too even before the advent of the digital era. I knew one such student in 1965, who would hardly attend a class for the whole year, but came out with flying colors. Not by fluke. Those were the days of no Internet, no computer and no photocopying. And his class of 30 students were already graduates or post-graduates undergoing a one-year course. The aggregate marks scored in about twenty tests evaluating as many subjects could make or mar the placement in a senior grade at the end of the year, just like the STEP 1. Hence, all other 29 students, except him, would take rough notes furiously during a lecture and write down the final version of the same in the evenings in their hostel rooms. This ‘super’ guy would borrow those notes from at least three of his classmates before they go to sleep, compare them, and make his own version of the notes for which he worked upto 4am every night, affording to get up late because he hardly went for lectures. But he mastered the concepts, often discussing some points with his classmates when he returned the original notes to them the next day, and invariably scored very high in written exams. Later, he also rose fast in his career, and proved to be a good leader of his team. But, this is possibly a ‘rare’ of the rarest cases. There is no recourse to slogging, both with lectures and learning beyond what is taught in class, because it equips a student with that extra bit of confidence to stay cool during the tests and interviews. And for medical students it would provide them the depth of knowledge while examining a patient to declare an accurate diagnosis, or handling the scalpel.

    Finally, I suspect that over 11,000 students who filled the questionnaire, perhaps did so in anticipation. Otherwise, how does one explain the percentage of students responding to a given question to be so close over a period of three years? For instance, to the query, “If you could revisit your career choice, would you choose to attend medical school again?”, those who said an emphatic YES, were 60.7%, 61.3% and 60.8% in 2015, 2016 and 2017, respectively!

  • When I went to med school (I graduated in ’97) the same thing happened. There is a tremendous amount of information to be learned, and often it is best done out of class. Additionally, many med schools have “note services” that consist of one classmate taking verbatim notes of the lecture for a fee. One typically could buy the note service for each individual class. Because the professors often (the majority of the time) gave the same exact lecture each year, if one bought the prior year’s notes, there was no risk of missing anything new in class. This allowed one to study the notes, look up what one doesn’t understand, re-read. Let’s keep in mind, the biggest emphasis for a med student is to learn as much as possible as efficiently as possible. Sometimes the lectures just aren’t congruent with that aim. And really, it shouldn’t matter, as long as at the end of the proverbial day we have well-informed doctors, which we do.

  • Why waste all that money and creating student loan debt on going to medical school because doctors can no longer treat their patients anymore? People go to the doctor when they are sick and in PAIN. But, since treating pain is no longer the case, people won’t go unless they have to. Medicaid/Medicare policy makers are putting doctors in jail for prescribing pain medication. Most clinics are deserted. Their jobs will be obsolete. That’s cruel and unusual to let people in pain suffer. It’s not right. It’s wrong. Who are these cold-blooded, heartless people? They’re coming out of the woodwork and being called to duty. You can bet your life that if someone in their family or group are in pain, they will get treated for their pain though. But, oh yeah, they won’t have jobs anymore either because they won’t be needed. Please believe there will be people making a lot of money providing cheap pain relief that the people of the United States need because there is going to be a demand and alot of competition for providing those products. It’s all common sense. There isn’t professional people, just educated idiots trying to make our decisions for us regarding our health and well being. 😠🆘️

  • This is a sad development. It is true that with the world’s knowledge in your pocket, epitomized by the cell phone, memorization of facts is not needed anymore.

    But wait, have we ever needed to ‘memorize’ in medicine, so as to not have to look up in medical encyclopedia? No. This is not the purpose for having to learn all these facts.

    Only the dumb and unschooled and unlearned think they need to memorize. I went to medical school in the 1980s. Very soon, most of us realized that UNDERSTANDING Latin and the principles of biochemistry and physiology and pathology drastically reduces the need for memorizing. The pressure to master this vast amount of facts forces the curious mind to place them into a framework of biological principles, thereby promoting a deeper understanding of how the human body works.

    Yes, in the worst case, such as with rare, unexplained diseases, some memorizing is still necessary, but mapping the facts onto a mnemotechnical patterns unrelated to biological principles is not the solution. A natural sense of wonder about nature will make you remember these strange syndromes.

    In the near future when every medical fact can be reliably googled using simple queries (that are, thanks to AI, understood by search engines), when evidence-based guidelines will be replaced by personalized “N-of-One” medicine – in this new medicine that is not far way, the key will be to understand the mechanistic principles of health and diseases, and use problem-solving skills to apply such scientific understanding to THE patient in front of you.

    Such understanding starts with been forced to know a lot of basic facts and figuring out how to make sense of them. A deep personal relationship to medical facts is established when we seek to place the facts into the context of biology as we are forced to memorize them as critically thinking, curious students of medicine. This attitude is stifled by using fancy, cold cartoons devoid of scientific principles to provide the context for remembering. There is no better teacher of critical understanding than the process of memorizing. At least, to get started. Later, we can rely on google, but we need to UNDERSTAND the search results. Such understanding cannot exist without past attempts to memorize them.

    • I don’t understand why you believe medical students don’t learn principles of biophysiology and place facts in larger biological contexts, nor why you think the use of mnemonics and memory aids precludes the study of such facts in their larger contexts. Nowadays, medical students are asked to learn more facts than ever for arbitrary standardized tests, due to the ever increasing numbers of students and an ever pressing need to stratify them. I’ve seen some of these tested materials, and it’s ridiculous what they’re tested on (some, I would argue, are nitpicky details that have almost no clinical relevance whatsoever, save for certain niches – and almost certainly, a medical student wouldn’t be able to place such knowledge in broader contexts effectively, and shouldn’t be expected to).

      To broadly paint a generation as non-critical thinkers memorizing for the sake of a test is a perspective that misunderstands the landscape, and draws a false comparison to a past with different expectations and less limitations. The fact is there is not enough time for all save the most brilliant students to take in and internalize and memorize all the details expected of them by traditional means. These are some of the smartest kids I’ve ever seen, trust me. I do believe there has been a stifling of the creative process of learning, but it is born out of necessity and not student preference.

    • For some perspective, when you went to medical school:
      MRIs were an oddity,
      ARBs, Statins, Sidenafil, Gabapentin had not yet been released in the US,
      Vicodin and Captopril were new drugs.
      Over the last 30 years there have been tremendous discoveries in medicine. New diseases, drugs, technology, physiology, and heck even some new anatomy. During that time, think of all the papers you’ve read, conferences you’ve attended, discussions you’ve had, consults you’ve made. Now realize that a large chunk of that information is a part of the medical school curriculum. This is why a knowledge of Latin and basic biochemistry and physiology will no longer allow you to excel in medicine.

  • My med school also utilizes the flipped classroom approach. I just started a couple weeks ago, but I prefer this over the traditional live lectures during undergrad. While it keeps attendance high because there are graded “clicker” sessions, I heard that many second year students, especially closer to Step 1, bite the bullet and don’t attend class to study more for Step. The few extra points just aren’t worth it.

    I just want to add that board exams are light years away from adapting. DO students are still required to take COMLEX and, of course, feel pressure to take Step 1 as the residency merger completes in 2020.

  • Sad – Granted, my graduate education was many years before these students – but, classes were important, at least for me. Clinical education/experience/training are essential -BUT after the “school work” – classroom experience.

  • Step 1 wasn’t mandatory to advance to 3 rd yr med school, so I didn’t take it until after 3rd year clinical rotations were done. THAT was what made step 1 a breeze. I never cracked a book for step 1, because I reinforced all the material in clinical context, seeing patients. Step 1 supposedly focuses on preclinical knowledge, but a year of clinical work actually USING the preclinical knowledge precludes the necessity of brute memorization for step 1. Problem is med schools don’t want to invest a year of clinical training into someone who won’t be able to pass step 1.

  • This skip-class model has been going on for over 50 years. One my best friends rarely attended class, but usually aced the exams. Funny that academia is just noticing the empty classrooms.

    MD programs seem to be drifting toward the way PhD students have learned for centuries. Most my classes were seminar discussions on a weekly or everyotherweekly basis. We were given a few articles to read and discuss. That meant many hours reading books and articles of relevance to discuss the assigned material. The professors acted more like referees. Not uncommon, we would have mini seminars in preparation at the local cafe. It is a great way to learn, great fun too. Of course, today the Internet modifies the model a bit. Chat rooms likely supplant some face2face cafe chats.

  • Students have mostly abandoned the idea that “live lecturing” offers a superior learning experience. The ROI is simply not compelling enough –– and they are probably correct! Experiential learning coupled with small group sessions and recorded lectures is preferable. An unfortunate consequence of our current system is its emphasis on test questions (ostensibly memory) rather than actual performance in the field. That said, the elephant in the room is USMLE step 1.

  • The hardest part of medical school is getting in. After that it is pass-fail and its near impossible to fail or the schools loses funding. It also helps that there are informal test banks where you can copy a usb with all of past years exams. A big reason for no one going to class is the partying. Sort of a frat/sorority like environment. Schools have the testing for all classes in the same week or couple of days, in “blocks”. Thats why we call them block parties. One guy bought a commercial sized margarita machine (no idea how he carried it down to the pool each weekend).

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