Beyond the White Coat

Teaching to the Test


This is the time of year when teaching to the test comes to the forefront. Standardized testing is endemic in medical training. Whether you are a high school senior taking the SAT, a college student applying to take the MCAT, a medical student struggling to pass United States Medical Licensing Examination (USMLE) Step 1, or a recent residency graduate sitting for the boards, taking a test can be a very anxious time. Careers can be markedly altered by the scores on the standardized tests. The reputations of educational institutions, including medical schools and residency programs, depend on the scores. So the anxiety is understandable.

On the other hand, the public – who are the future patients of these physicians – may have a different perspective. Do these tests really evaluate and select those who will become better physicians? Will those physicians have the optimal balance of scientific knowledge and the art of caring?

That has been a source of consternation since long before computers began scoring tests. This quandary has not been lost on medical educators. The MCAT itself will be undergoing an overhaul by 2015. The goal is to have "A Better Test for Tomorrow’s Doctors." A preview guide of those changes was released in November 2011, and the revised second edition was just released in September 2012.

The MCAT’s basic science questions, which previously focused on biology, physics, and chemistry, will now include a section on the psychological, social, and biological foundations of behavior. The intent is to select a more diverse group of medical students, some of whom have studied sociology or anthropology, rather than favoring the hard science majors. There will also be a "critical analysis and reasoning skills" section of the test. In modern medicine, regurgitated, memorized facts are not as important as being able to interpret and apply them. There are other initiatives, such as the Project to Rebalance and Integrate Medical Education (PRIME), seeking to overhaul the medical curriculum.

Medical education 30 years ago involved large didactic lectures wherein a vast amount of information was transmitted from professor to student, then crammed and forgotten. Memorizing facts was considered the key to being a competent physician. The most lauded professors were frequently referred to as walking textbooks. But that is no longer adequate. Medical knowledge is now a bookshelf of textbooks, well beyond the memorization of a single person. The photographic memory aided by cute mnemonics has been supplanted by a smartphone and Google.

The provision of medical care also has evolved. Rather than a solo practitioner in an office, now a team of subspecialists, aided by nurses and allied health personnel, provide care in inpatient and outpatient settings. My role as a hospitalist is to stitch together the various patches of expertise each team member has, to form a quilt that covers all the patient’s needs. Communication between team members is crucial. Accurate and complete handoffs of information also have become vital in the shift-based environment for delivering therapy in most hospital settings.

As a patient, I was quite annoyed when, after a day of tests and procedures, I was handed a computer form to fill out. It surveyed my "experience." Did I have any trouble making the appointment? Were the hours convenient? Was the staff courteous? It contained 22 items, but only one question seemed to have anything to do with whether my physician was competent. Perhaps we are in a consumer-oriented society, and the provision of medical care needs to reflect that with Press Ganey scores. But the engineer in me still focuses on those key goals of getting the diagnosis and therapy correct. Especially when I’m the recipient!

Will changing the test produce, and importantly, maintain, a more competent physician? What are the consequences of better patient satisfaction? Not necessarily better health, according to one large study. Higher patient satisfaction was associated with less emergency department use but greater inpatient use, as well as with higher overall health care and prescription drug expenditures (Arch. Intern. Med. 2012;172:405-11).

If medical educators teach to a better test, will society simply run into a better mousetrap?

Dr. Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial disclosures. E-mail Dr. Powell at This column, "Beyond the White Coat," appears regularly in Pediatric News.

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