Tailoring Medical Education's Means to Medicine's True Ends

We are thinking of two very different medical students. One, Conrad, aimed at nothing more than to outperform his classmates academically, while the other, Clare, sought above all to care well for patients.

At every stage of his academic career, Conrad had distinguished himself as a star. He consistently earned the top grade on every medical school test he took, and prior to medical school, he had earned a higher score on the Medical College Admissions Test than most faculty members knew to be possible, completed his undergraduate education with a perfect 4.0 grade point average, graduated as valedictorian of his high school class, achieved a perfect score on the SAT, and ranked as the top student in his class throughout his education. Although we do not know, we suspect that his Apgar scores were 10/10 and 10/10. Moreover, he went on to graduate at the top of his medical school class, and he matched to a residency position in one of medicine’s most competitive fields at one of the nation’s most prestigious institutions.

The other student, Clare, had followed a rather different path. In grade school and high school, she had been a mediocre student, more engaged in extra-curricular activities than her studies. Failing to gain admission to a four-year college or university, she started her collegiate career at a two-year community college. There she managed to obtain a degree and entered the workforce. After some years, she felt a calling to medicine, enrolled at a four-year university, and obtained a degree. Her grades and test scores were good, but she initially failed to gain admission to medical school, so she worked as a medical scribe and nurse’s aide before eventually garnering a place on the medical school’s waiting list. Just before classes started, she learned that she had been admitted. Her academic performance in medical school was below average, but upon graduation she did match at a community hospital-based primary care residency.

The trail of transcripts, diplomas, and academic prizes does not tell the whole story about either of these students. Blessed with an unusually high degree of intelligence, Conrad was a textbook example of what we once referred to as a gunner. In whatever situation he found himself, he quickly determined how performance was being assessed, then adopted approaches to learning designed to enable him to outperform everyone else. Knowing, as all clever students do, that it is impossible to learn everything, he focused like a laser on learning what counts – that is, the recall or application of knowledge that would earn him a higher test score and grade. In every learning situation, his first question was this: “Will this be on the test?” If the answer was no, he did not allow himself to be distracted by it. In Conrad’s mind, the ends and purposes of medical education were coextensive with his academic performance.

Clare, on the other hand, saw matters differently. To her, tests and grades never felt as real as some other things she encountered in medical school. Much of the time, Conrad was hunkered down in his study carrel working his way through yet another deck of multiple-choice question flash cards, but Clare could often be found engaged in activities that served patients and the community. For example, she was a regular volunteer at the medical school’s free health clinic for disadvantaged patients, where her dedication eventually landed her the role of clinic manager. Truth be told, Clare could never fully commit herself to the medical school’s steady regimen of multiple-choice tests, and she often found herself thinking that there had to be better ways to use her time. In at least one instance, her test aversion got her into trouble, when a poor performance forced her to repeat a class.

Conrad loved tests, in part because they provided him means by which to demonstrate his superiority. For someone to remove tests from the medical school experience would have deprived him of both his identity and his reason for being as a student. Clare, by contrast, and without being able to put her misgivings into words, always regarded tests as somehow inauthentic, or at least far removed from her vision of what it means to become and excel as a physician. It was not just that patients never show up with multiple-choice questions concerning their diagnosis and treatment pinned to their gowns. To her, it was more that practicing medicine meant being present with patients, including the connection she could establish with them and the compassion she was able to express in caring for them, their families, and colleagues. Test scores seemed to her to leave out so much of what really counts.

The fundamental difference between Conrad and Clare was clearly on display in one class session during their second year of medical school, when they gathered with their classmates in a large amphitheater-style classroom for the presentation of a patient’s case. Within minutes of the patient entering the room, Clare was entranced by the story, and throughout the hour, she never looked away. When the patient described the toll her disease process had taken on her life, Clare was moved to tears with her. Although she and the patient were separated by multiple rows of students, it was apparent that Clare was right there with the woman the whole time. Conrad, by contrast, took only a few minutes to determine that, though the patient’s story was in some ways interesting, it represented material that would never appear in any multiple-choice exam. So he put on his earphones and spent the remainder of the hour working his way through his deck of flashcards, never looking up.

There are details in the portraits of these medical students that clearly date them. For example, no student today would carry around decks of multiple-choice question flashcards. Today, a student like Conrad would be focusing his attention on electronic learning resources. Unless class attendance were mandatory, it is highly likely that he would not be found in today’s classroom, as he would have determined that attending classes represents a relatively inefficient way of preparing for exams. If there were material being covered in the classroom that he felt obliged to familiarize himself with, he would likely access class recordings asynchronously, reviewing them at 1.5- or 2-times speed. In most or perhaps all cases, he would wherever possible entirely eschew the teaching efforts of the medical school faculty, whose presentations he would likely deem a “low-yield” way of preparing for tests, opting instead to reallocate precious study time to his flashcards.

At stake in the contrast between Conrad and Clare is a fundamental and largely moral question; namely, what is the end of medical education? One such vision, which we might refer to as testocracy, or rule by tests, presumes that educating physicians is primarily about selecting, sorting, and credentialing both candidates for admission and learners already admitted to the profession, and doing so as objectively, fairly, and above all, as efficiently as possible. On this account, we can best distinguish high performers from low performers – including those fit to be physicians from those who fall short – by subjecting all medical students to the same testing and scoring regimens. When each candidate is evaluated in exactly the same way, we suppose, we need not worry that we have been unduly influenced by subjective factors, that some candidates have been discriminated for or against, or that we have devoted undue time, attention, or financial resources to the assessment process. On this score, students such as Conrad represent the very best medicine can hope to offer to the profession, our patients, and communities.

Yet alternative approaches are also possible, grounded in different conceptions of the end of medical education, which in turn flow from alternative visions of a physician in full. Suppose, for example, that performance on standardized tests, while useful, does not tell us everything we need to know about a candidate for admission to medical school, or how well students are performing during their medical education. While such exams may offer insights on a student’s fund of knowledge and problem-solving ability, they offer little insight into other important attributes such as the capacity to communicate, creativity, and character. Will a student such as Conrad be a good listener, build good rapport with patients, think “outside the box” when it comes to understanding how patients’ illnesses and injuries affect their lives, and prove to be a compassionate, generous, dedicated, and courageous human being who genuinely cares for his patients and can be relied upon to put the interests of his patients above his own? We might call this approach aristocracy, or rule by moral excellences.

Conrad’s test scores, and the substantial difference between his scores and Clare’s, provide little or no basis on which to draw moral conclusions. We simply cannot adequately assess attributes such as communication, creativity, and character based on standardized, multiple-choice tests scores. To gain insight here, we need to read essays, engage in conversations, and perhaps observe – or even better – work side by side with learners to gain a sense of who they really are, not just as test takers but as human beings. And yet test scores are so seductive, possessed of such a seemingly scientific character, that we often find ourselves placing greater reliance on them than we should. It seems easy to say that a student who scores 90 is somehow better than one who scores 80, while it is much more time-consuming and potentially fraught with peril to compare two students on an attribute such as compassion. Could it be, for example, that a savvy student could fool us?

The stakes are high. In order to care for human beings, we must first become human beings, and what is needed in medical education is some means not only of assessing but also developing the whole person. We must avoid wherever possible the temptation to let the means dictate the ends, for when we do, we become the tools of our tools. The fact that some abilities are easier to assess than others – among them fund of knowledge and problem solving – does not imply that such attributes should crowd out other, equally important ones. To make standardized, multiple-choice tests the backbone of medical education is not only to fail to adequately assess other vital learner characteristics but also to misdirect both the learning objectives of students and teaching objectives of the faculty. The tail of ease of assessment should never be allowed to wag the dog of what makes a complete physician, and failing to respect this truth represents one of our greatest contemporary lapses in treating medicine as the deeply moral practice it is.

The point here is not to suggest that medical education should be characterized as a fork in the road, where we must choose between developing Conrads or Clares. Instead, the question is one of balance, and we believe that many contemporary students and faculty members have allowed the apparent ease, low cost, and objectivity of multiple-choice testing to so seduce us that moral development has been relegated to the back seat. To correct this, we might look beyond sophisticated psychometrics to learning resources of an entirely different sort, including great literature such as Sophocles’ Philoctetes, George Eliot’s Middlemarch, and Leo Tolstoy’s Anna Karenina, which aim not to fill learners with readily testable knowledge but to enrich the moral imagination. The Conrads and Clares of this world, the patients and communities they will serve, and those who will practice alongside and succeed them in the profession of medicine are all counting on us to strike the appropriate balance.