A Guide for Tough Basic-Sciences Teachers

As medical school basic science teachers, our primary responsibilities are teaching the essential facts that will enable students to think about disease, and certifying a basic level of knowledge in our medical students. Generally we do this well, even though few of us are trained educators.

Although most of our students learn effectively, each of us must sometimes counsel students who are failing our courses. It is not really our job to make sure that every student passes. However, every medical student has excelled in a rigorous pre-medical program, and every impending "F" presents a problem in differential diagnosis.

The author is not a clever, thoughtful, or perceptive person. However, most anyone can learn from mistakes, and a medical education does make it easier to understand people. If you want to reduce the number of students failing your basic science course, you can help by (1) avoiding the problems that cause multiple "F"'s in a single class, and (2) identifying and treating the problems of individuals.

Helping the Entire Class
Avoiding the Problems that Lead to Multiple "F"'s

If several students fail each time you give your course, or if you must adjust your grading policy to prevent this, you have a problem. There is probably something you can do to reduce the failure rate without lowering your standards. Now is the time to examine (1) your published learning objectives, (2) the kind and level of activity in your labs, (3) your image as a "fair" teacher, and (4) your examination and grading practices.

1. The better you define your learning objectives, the better all your students will learn.

Most medical students probably enjoy learning medicine for its own sake and for their future patients. However, they focus on passing exams. In our imperfect world, medical students often ask: "What are we responsible for?"

Don't be put off by this question. Instead, anticipate the need for study guidelines by publishing learning objectives, and adhere to these objectives in preparing your examinations. Today, all teachers at the elementary and secondary school levels rely on objectives. Students at any level need to know what to learn. This is doubly true when they approach a big, complex subject like a basic science. The wise basic-science teacher prepares educational goals with great care, remembering what his or her students need to know, and what they already know. You need a list for each instructional unit, and it is best when objectives, lectures, and textbook all follow the same sequence. In my experience, writing objectives takes about thirty minutes for a one-hour lecture, and fifteen minutes for each hour of lab. One hour's lecture objectives should cover about one page. The Group for Research in Pathology Education (G.R.I.P.E.) has written objectives for the introductory pathology course, though every pathology teacher will want to modify these for his or her units. If any lecturer publishes objectives, students will want them from everyone.

Good learning objectives are the first step in guaranteeing meaningful lectures. A good lecture is still "the best way to transmit a large amount of information quickly and efficiently to a large number of people", and should arouse an active interest in the students, who can then pursue the material on their own. In a bad lecture, poorly-related facts are repeated by a lecturer, while students frantically take notes to memorize for an exam. One author calls this "a superficial transfer process whereby the lecturer's notes become the students' notes without passing through the minds of either." Yet the same author demonstrated that learning does occur when a lecture is "carefully prepared in conformity with pedagogical principles, being targeted at specific learning objectives." We often hear that "lectures should emphasize key concepts and focus on what is important, rather than on picky details". The best way to do this is by providing learning objectives up front, giving the focus that enables the students to master the material. And if you want to talk about some exciting research but not hold the students responsible, learning objectives will allay any anxiety. Today's lecture should be an overview with pictures, stories, and thought-provoking questions, designed to equip students to begin mastering specific educational goals.

If you use simple lecture handouts, list your objectives at the beginning. This is the most important part of the handout, and students will focus on it as they learn. The rest of the handout is meant to keep the lecture moving at a reasonable rate. It should consist of a brief outline, with an emphasis on new terminology, important lists, and possibly references or textbook errata. Few of your students have pre-read the textbook or know the vocabulary items, despite your exhortations. If students have a simple handout, you can cover much more ground with fewer interruptions.

If you use more elaborate handouts, you are telling the students to focus on the handout rather than on the lecture or the textbook. Prepare a lengthy handout when, and only when, you are more current on the subject than the textbook, or you want more depth, or you know you can do a better job. The long handout becomes its own objectives sheet, and students read the textbook to clarify lecture and handout. An example of typical objectives for a relatively intensive lecture is provided in Appendix I. On a big handout, you will probably want to designate blocks as "non-testable" or "for your interest only". (I use asterisks for this.) Comprehensive handouts greatly speed up lectures and are popular with students, but they have been blamed for promoting passive (and therefore ineffective) learning. If you decide to use comprehensive handouts, this makes active labs and discussion time even more important. Also remember that at most schools, if you do not provide a relatively detailed handout, the students will produce an inferior version through their "class note service".

Someone must decide whether to require your students to read the textbook in order to accomplish the objectives. Failure to do this generates confusion and places weaker students at risk. The book you designate as the "course text" depends largely on your philosophy, and the level at which you want students to read. An even more important decision is to decide about required reading (and whether that really means testable or "we just want you to buy it" -- students will scoff at the latter "requirement"), recommended reading ("preview, review, and look up the things you don't understand from lecture"), and library reserve books. Generally, each unit lecturer makes decisions about whether "the book" is testable, even if there is a "course policy". No matter what book you assign, remember that your students will ignore your recommendation and choose their own favorites.

Only if you have published your objectives will your weaker students make effective use of lectures, textbooks, and the other resources you have made available. If a lecturer does not publish objectives, students will ask that lecturer, "Are we responsible for everything in lecture?" (usually the answer is "Yes"), and then, "Are we responsible for everything in the book?" Now you cannot win. If the lecturer says "No", most students will only look at the chapter if the lecture was confusing. If the lecturer says "Yes", but asks questions only from lecture, students will resent "having wasted time reading the book". If the lecturer says "Yes" but plans to ask one or two obscure points "to test your reading", students will be even more resentful. If the lecturer says "Yes" and tests mostly out of the book, students may stop coming to lectures.

Anecdote 1: The author, as a beginning course director, added a few questions to an exam, taken from the textbook "to test their reading". This material had been presented by a different lecturer who had apparently said, "Just know my lecture." The author was surprised when the students hanged him in effigy -- but he shouldn't have been.

Further, students who "did not hear through the grapevine what we were responsible for" will not only be very angry, but also will be at increased risk for failure "because they studied wrong".

At all levels, objectives are usually phrased "in behavioral terms", as something students must be able to do. This provides structure and motivation for learning, and enables you to make clear to all students the degree of familiarity with the material that you will demand. If you tell students to "remember the stuff on ulcerative colitis from lecture and Big Robbins", they will feel like sponges, and the weaker ones will also feel confused or overburdened. If you tell the same students to "explain what clinical features would lead you to suspect ulcerative colitis, and what abnormal anatomy would enable the clinician and pathologist to make the diagnosis", even the weak ones feel like doctors with a job they can learn.

Key words for behavior-defined basic-science objectives, from the least to the most demanding, include "recognize-identify", "recall- name-list-define", "discuss-describe", and "explain-critique". Of course, clerkship objectives are "do-perform". Replace "appreciate", "believe", "know", and "understand" objectives with behaviors you can observe. You can supplement these "cognitive" objectives with "affective objectives". These begin with words like "participates", "questions", "defends", "rejects", "investigates", "designs", etc. For a course in medical terminology, recognition might be your primary goal. A typical objective would read: "Given the name of a tumor, tell whether it is benign or malignant", and your exam question asks: "Are leiomyosarcomas benign or malignant?" For the medical school level, you would demand a much higher level of performance. Your objective reads: "Given a tissue of origin and data including malignancy, name the tumor", and your exam asks: "Name the malignant tumor arising in smooth muscle." You can use "compare and contrast" items for exams, but try to preview real physician skills in writing your objectives: "Describe the causes, gross and microscopic anatomy, and clinical picture in ulcerative colitis, and explain how clinicians, radiologists, and pathologists distinguish it from regional enteritis."

Feel free to discuss historical aspects of your subject, but without including these in your objectives. The classic discussions of educational objectives consider a course in electric toaster repair. The most appropriate objective is, "Given a broken toaster, fix it so that it works." The least appropriate objective is, "Name the inventor of the toaster and recount its history." Historical items remain very useful in explaining nomenclature and illustrating principles.

Be careful when preparing objectives on subjects that might be sensitive. If you offend any students, you have lost their attention and increased their risk for poor performance. Rudolf Virchow emphasized that social and political factors are major causes of disease. However, you must avoid "social conscience" or "attitude" objectives whenever any student might feel you are trying to impose your politics. You might ask students to remember how much money is spent on the average AIDS patient, or even to briefly describe "the politics of AIDS care", but you would never examine students on how public money "should" or "should not" be spent on the care of "helpless victims of this tragic disease" / "people who caused their own disease through immorality and who are going to die in a few weeks no matter what you do." You can discuss antenatal diagnosis of Duchenne's muscular dystrophy, but you would never ask students to "recognize diseases for which a fetus should definitely be aborted." Since some medical students are scandalized by "evolution", I make sure my students know from the start they will not be asked about "the history of life". After this, I have no problems if I mention the conservation of gene sequences over time, the origin of our peculiar kidneys, and the reason we have a vermiform appendix in the first place. And if you criticize a health fraud, explain why -- instead of being offended, misinformed students will realize you have done them a service. If students know your own beliefs, you may want to announce at the beginning of the course that nothing pertaining to politics or religion will appear on exams.

As at any other level of education, the most important technique to ensure that your students learn is to tell them what you want them to learn, and then test them on it.

2. Your students will learn lecture and reading assignments much more effectively if they have had the opportunity to learn actively in lab.

Lab is the students' opportunity to use the material they must learn. A good lab requires much more than "just looking at the specimens". People really learn only when they are doing something meaningful. This was a primary focus of the GPEP report. Medicine is a dull spectator sport. Students know it is a waste of time to "pass this emphysematous lung around and everybody look at it", or "find an asbestos body on your own slide", or "all make short presentations on different topics". (The latter is a good way to generate minor expertise and get data on which to evaluate the students). But it takes only a little imagination and preparation for a knowledgeable instructor to make the lab experience worthwhile. If your course is just starting, assign the students to write and produce a skit called "Inflammation", with class members playing the bacterium, the endothelium, the neutrophil, the macrophage, the fibrin, etc., etc. If today is your first gross lab, have one student "describe what's abnormal about this lung for your classmates." If you have a tray of organs from an autopsy, assign six students to "reconstruct the patient's clinical course based on what you see, and tell it to the rest of the class". If you have ten glass slides, coach ten students as teachers and have them instruct their classmates (the harshest critics). If you have enough students, take last week's "New England Journal CPC" and hold a malpractice trial, with different people playing plaintiff, defendant, attorneys, judge, and each side's expert witnesses. Passers-by will stop and watch.

Anecdote 2: When the author was a beginning course director, he ran a typical boring lab ("Sit at your microscopes and look through them for two hours"). Attendance on a good day was 2-4 students out of 56. When seats were assigned and attendance was monitored, students still refused to show up. Instead, they learned morphology by viewing lecture kodachromes together in the library in the evenings. At the students' request, the author began holding weekend "office hours" at the department's multi-headed microscope. These lively interactive sessions focused on correlating abnormal morphology with clinical findings. "Ed's rounds" proved so popular that the students worked out their own schedule to ensure everyone a seat. Encouraged, the author introduced "meaningful fun" into the lab, and soon attendance was close to 100%.

Because lab is the time in which students "use" lecture material, it is also your opportunity to demonstrate relationships among major concepts, and to reinforce the unifying principles that the lecturers have presented. Seeing how concepts are related to one another, and to what students already know, is the key to meaningful learning -- the only kind that "sticks" and can be used. Most students at high risk are the ones who miss the big pictures and rely on rote memory. If you are lab leader, you can force meaningful learning simply by asking questions that begin "Why?"

Students who are at risk for failure will stand out as bewildered non-participants in any meaningful lab exercise. You will recognize them quickly and can intervene. Further, looking bad in front of classmates breaks down denial. Students also know (without being told) that the lab will be the chief source for the narrative portions of their evaluations. More generally, an active lab should energize your entire class, greatly enhance understanding, and significantly improve overall performance.

3. Your students will learn effectively only if they perceive you as a fair examiner and grader.

If people have any reason to blame anyone else for poor results they will not address their own deficiencies. By the way, if the entire class perceives you as unfair, most members will be afraid to tell you.

The most important way to be perceived as "fair" is to be sure that all students will pass comfortably if, and only if, they have mastered your published learning objectives. My rule of thumb is that students who can do all the objectives fall in "A"-range, or 90-95%, whichever is higher. To reward the student who achieves above the rest of the class, feel free to ask a small number of bonus or challenge items (you must designate them as such) which were not covered on the learning objectives but were treated in "recommended outside reading" or in portions of the textbook not designated as "testable". As long as the rest of the class knows what it must do to pass, there will be no charges of "unfairness". Also, each hour of lecture (and generally each "point") should be weighted equally in the final grade. Otherwise, failing students will complain that they "studied the wrong stuff".

Your required level of performance for passing (or for particular grades, if you have them) must be clear from the beginning, and must be criterion-referenced. This is absolutely critical. Never "draw the lines once the curve is established." This is absurd if you have established learning objectives, especially in a school which aims to turn every qualified student into a physician. And it will make your students livid with rage.

As much as possible, avoid subjectivity in your grading. If you use fill-in-the-blank, short-answer, or essay questions, publish the right answers on the key, along with acceptable and expected wrong alternatives. For essays, tell exactly how many points each component earns or loses. (Perhaps your maximum may exceed the maximum for that question. You may need to modify your essay key as you grade, if unexpected responses are common.) Having an essay key not only makes your job as grader much easier, it also prevents most of the (otherwise inevitable) charges of "favoritism" in grading.

If at all possible, post your key promptly and deal with all challenges before you begin the grading of tests. The first student to finish can post your copy of the key outside the room. ("The key is up, no more bathroom breaks.") Students appreciate the instant feedback, and it helps you too. Ten minutes after your students have begun looking at the key, they will have suggested every alternative answer, found any errors on the multiple-choice portion, and identified every bad question for you. Every teacher writes an occasional unfair or ambiguous question. When you recognize a stinker, you must choose between dropping it (and lowering the exam total), and giving everyone full credit for the question. The latter costs you very little.

Humor is an appropriate part of examinations, and most medical school teachers are gifted humorists. It is important to avoid the temptation to deduct real points for "trick", "joke", or "gag" items not related to your objectives. Don't ask questions like, "If a plane full of Canadian citizens, flying from Chicago to Denver, explodes over Kansas City, Missouri and lands across the border in Kansas, who signs the autopsy permits for the survivors?" If one of your lecturers submits a really inappropriate question, discard it.

Anecdote 3: The author has had to reject "pathology" questions that ask the meanings of Latin phrases that the students have never seen, the names of members of rock and roll groups, and whether armadillos have front teeth.

If you want to indulge, give everybody credit for the item. (I always end exams with a photo of myself or a willing student, with the question, "Why is this man smiling?" All answers are counted correct.)

If different students perform for different lab instructors, it is very difficult to grade uniformly unless the lab portion of your course is pass-fail. A student with a legitimate "F" in an active lab is obvious to teacher, fellow-students, and self. You can have a policy that a student who fails lab fails the course, provided that feedback to the student has been adequate.

You can avoid another "fairness" pitfall by designating which textbooks are authoritative for exam challenges. Be sure your lecturers know this, and adhere to this policy unless a lecturer has issued a specific warning. The most enterprising students will use the current literature to prove you wrong. When this happens, you might as well award the point. Also announce that you do not accept challenges based on errors in the "class notes". Otherwise, students will tend to hold you responsible for errors in their own "class notes", even if you have never seen them.

If you are course director and your students perceive an individual instructor to be unfair, you are in a delicate situation. Good luck.

4. Your examination and grading policies drive the learning that prevents failures.

Your examinations should assess and promote learning without driving the students crazy. If you plan appropriately, your exams will force the students to keep up with the material, and to study so that it is meaningful.

Test your students as often as politically feasible, up to a limit of about one test hour per 10 hours of lecture and lab. Frequent testing prevents students from falling behind. Medical school subjects build on themselves, and we all know that a poor start in the introductory course is fatal. And even with a good knowledge of basics, no one can get a real grasp of the pathology of several organ systems, or the intricacies of multiple metabolic pathways, or the subtleties of blood pressure regulation, all in a few days of cramming. Test often -- and never test less often than any other concurrent course. Although it is irrational, many medical students spend almost all their study time preparing for whatever exam is scheduled next. If "Microbiology" tests twice as often as the concurrent course in "Pathology" does, they will study microbiology twice as much, and learn pathology only half as well. Keep the war going until the administration intervenes.

If your school permits quizzes, give them frequently -- announced or unannounced as policies permit. If a quiz counts even a tiny fraction of the grade, medical students will spend hours studying for it. If your school has a policy banning quizzes, give them anyway, for "self-assessment" rather than for a grade. This is still a potent motivator, and you can read the worst answers to the class without naming writers. Give quizzes at the beginning of class, or the students will study yesterday's material during today's lecture.

The best exam questions for the medical school level are those that force recall rather than recognition. These readily identify students who do not understand the material. "Multiple-choice items" can be handled adequately by any student with a good short-term memory for word-associations. "Recall" items closely simulate the ultimate behavioral objective -- practicing competent medicine. ("Patients coming through the emergency room door don't have 'Choose the one correct answer' pinned to their clothes.") Fill-in-the-blank questions demonstrate real learning much better than "multiple choice". Students also study "differently" (i.e., harder, and using effective forced-recall and organizing techniques) when they expect "fill-in-the-blank" questions. (A typical fill-in-the-blank question is, "Name the malignant tumor that arises from smooth muscle.") A series of short-answer questions is the best way to test a broad understanding of the content areas. (A reasonable short answer question is, "Explain how we think myc gene translocation leads to Burkitt's lymphoma.") Longer essay questions are less appropriate, especially in courses that focus on terminology and relating basic ideas and facts. One long essay question might be, "Describe the various patterns of inflammation that are seen in the systemic autoimmune diseases, giving specific examples".

The only real disadvantages of "recall" items are that you must grade them by hand, and you have to make a little more effort to be fair. You will be richly rewarded for your extra work. Remember that many students dislike "recall" items because they have to study harder. From time to time, students claim that "they need practice with type-K questions to prepare for National Boards". I suspect (but cannot prove) that if the questions are poorly prepared, a weak student can often beat them with testmanship skills. Fortunately for you, the course directors in the other subjects have probably decided to ask type-K questions, the students "get their practice", and you can ignore their request.

If your learning objectives are sufficiently comprehensive and you test over them, "recall" exam questions prevent students from concealing basic confusion and ignorance. On multiple-choice tests, the student at risk for failure often scores only slightly lower than the rest of the class. When such students are warned of impending failure, they will generally challenge the validity of your test, and someone in a position of influence will believe the student who says "the test didn't give me a chance to show what I knew." By contrast, recall items make it horribly obvious when someone is not learning. Try this -- on your first test, along with more challenging items, ask for definitions of essential terms ("pus", "fibrin", "neoplasm"). You will know immediately who is lost, and no one can deny it.

Medical school basic sciences that are largely visual, such as anatomy and pathology, need to focus on (i.e., tested on) pictures or specimens from the beginning of the course. There are many alternatives to the traditional dissection lab in gross anatomy. Kodachromes, fresh organs, and preserved organs all have advantages in pathology teaching. At most schools, students look at the pathology lecture kodachromes together on their own time (group learning-discussion, a good thing). A little clinical history or some other hint goes with most morphology exam questions.

Students at risk for failure will be alerted to this fact if your old exams are available. Students evaluate their own study efforts primarily by looking at your old tests. It's generally best to return these to the students, who will pass them along to succeeding classes. Or you can put them on reserve in the library. (Supply three copies and be prepared to replenish, as they will disappear.) Returning tests also prevents students from teaming up to memorize "the questions you ask every year", and giving (or even selling) copies to succeeding classes. You will have to generate new questions year by year, but surely you can think of plenty of good items. If you can't afford to make xerox copies of the exams, you must announce that no challenges will be accepted after the exams are returned if there is any evidence of erasure. Otherwise, a few unscrupulous students will change answers and ask you to correct your "grading errors". The class will usually agree to this as a condition of the exams being returned.

Anecdote 4: Applying all these principles to the introductory pathology course at UMKC caused an immediate increase of 92 points (almost a full standard deviation) on the class mean on the NBME pathology shelf examination. Although they had worked harder than previous classes, the students seemed generally pleased with the new approach.

Helping the Failing Student
Identifying and Treating Individual Problems

If you have adequate curricular time, and prepare your learning objectives well, and follow the other guidelines above, the large majority of your students ("the curve") will pass any reasonable exam, including standardized ones. You will also have no trouble recognizing students at risk for failure. Each of these requires special attention.

1. Some of your students will have medical or situational problems that interfere with their performances in the basic science courses.

The published literature about "problem medical students" is bloated with studies about the extent and causes of emotional troubles and substance abuse among medical students. There are rare studies of what eventually happens to students who have been in academic difficulty . There are almost no other data, and only a few anecdotes. There are few guidelines for course directors who want to help. Especially annoying is the use of the term "impairment" for a wide variety of conditions. This confuses the many individual situations affecting medical students.

If you are also a clinically-trained physician, these skills should go a long way to helping identify problems. If you do not have an M.D. degree, get a physician's help if you are at all suspicious of a medical problem. If you have shown interest, concern, and respect to students, they will tell you about problems. Since no one school has enough basic-science failures for a big series, reports of various solutions remain "anecdotal".

First, consider whether the student might have an organic disease. Subtle illnesses might include hypothyroidism, hyperthyroidism, hypoadrenocorticism, lupus, mononucleosis syndromes (Epstein-Barr, CMV, also HIV and maybe toxoplasmosis), disabling headache (remember migraine and cluster), the newly-described "fatigue syndromes", or any early brain disease.

Anecdote 5: A medical student in the author's class at Northwestern felt run down and had trouble studying. This lasted for several months and he was told by a non-physician counsellor he was "depressed". He noticed shortness of breath on climbing stairs, and a physician found a hemoglobin of 5.6% and guaiac-positive stool. Endoscopy showed a large duodenal ulcer.

Anecdote 6: A medical student at East Tennessee State had an erratic academic record and was found to have a platelet count of 74,000 when the students checked their own blood in the author's pathology course. The student refused all further workup, including tests for lupus.

Ask the student whether he or she is taking any medications. The benzodiazepines are notorious for impairing memory, and some over- the-counter preparations for "colds" and "diarrhea" contain amnesic drugs such as scopolamine and atropine.

Anecdote 7: A medical student at East Tennessee State had an extremely erratic performance, and repeatedly complained that he "sometimes just couldn't remember anything." After being seen by several counsellors, the author elicited the information that a physician had given him a large supply of "Valium 10 mg" which he took "to stop having so much anxiety over learning". Discontinuing this potent memory-impairing drug led to a dramatic improvement.

Currently students self-medicate for "anxiety" with propranolol, which may be easier on the memory but which might cause depression.

Even though you are not a psychiatrist, you may pick up clues to schizophrenia, major affective disorder, overwhelming anxiety, or reactive depression. Some studies indicate that medical schools select for people who are predisposed to depression. Get expert consultation if you have the slightest suspicion of psychiatric disorder. It helps to point out to the student that almost every physician seeks a psychiatrist's counsel from time to time.

Anecdote 8: Although a medical student known to the author was having auditory hallucinations and exhibiting bizarre behavior, she completed a year of junior clerkships without being examined by a psychiatrist.

Medical student anxiety seems most strongly related to "peer competition" and "having too much to learn in too little time". The suggestions given under "Helping the Entire Class" will make your own course a less anxiety-provoking experience. Beyond this, there is nothing you can do about the anxiety and depression that are generated by our system of medical education. Keep in mind that moderate degrees of anxiety and compulsivity probably do not predict medical school failure, though passivity, withdrawal, and weak motivation do.

There is a growing body of evidence that occasional medical students have subtle reading, perceptual, and learning problems unmasked when they are required to perform at medical school level. Ask about problems with reading in grammar school, letter reversals, and using a mirror to read. Isolated low scores on sections of standardized tests are another indicator. Despite overlays of anxiety and confusion, these problems are presumably organic, and Marshall University even has a program to treat these students. If you have any doubt, get psychological testing for your students.

Try to learn about the student's relationships with the family of origin, spouse, boyfriend, girlfriend, and/or children. Problems may range from spending too much time with a partner (especially if this is the first time the student has been "in love") to horror stories. Remember that, even today, minority and female medical students run into special problems, despite the favorable impact of support groups and the success of programs that prepare disadvantaged students for the rigors of medical school. Current, thought-provoking discussions of continuing problems are available.

Anecdote 9: A freshman medical student at East Tennessee State failed both anatomy and biochemistry. The author elicited the information that he commuted every weekend to Chattanooga (5-6 hour drive) to spend Saturday and Sunday with his fianc‚e. He received counselling and married the girl, and rose almost to the top of his class by the time he graduated.

Anecdote 10: A medical student at East Tennessee State had a record of erratic performance and behavior. The author elicited the information, previously unknown, that the student's brother had been sent to prison just before the onset of the problems.

Anecdote 11: A medical student at East Tennessee State, the son of two physicians, had a generally poor academic performance. The author elicited the information that he felt obligated to spend every weekend "playing" with a profoundly retarded, 17 year old sibling whose care had drained most of the family financial and emotional resources. The student received counselling, improved his performance dramatically, and was accepted into a prestigious cardiology residency.

Anecdote 12: A medical student at East Tennessee State failed his first pathology examination. The author elicited the information that the student's fianc‚e was a poorly- controlled schizophrenic, and that the student blamed himself. The tearful student was given a review article, which convinced him that he was not responsible for her mental illness.

Anecdote 13: A medical student at Northwestern who lived in the author's dorm suffered a significant drop in performance after his family disowned him. He had refused to take time off from school to spread the faith in which he no longer believed.

Anecdote 14: A medical student at East Tennessee State had an erratic, generally poor performance. The author elicited the information, previously unknown, that the student and his three siblings had been abandoned by their divorced mother when the student was fifteen. One sibling was now a fugitive from the law. The student had been raised by a kindly neighbor, but had not worked through his feelings. He was referred for counselling, took a year off, and did reasonably well after returning.

Anecdote 15: A medical student at Brown who lived in the author's dorm suffered a significant drop in performance when he became engaged to a woman of a different religion. His parents had held the traditional funeral for him, and sent notices of his death to the family friends. The student received counselling.

Anecdote 16: A medical student with an extremely erratic record had a major conflict over his relationship with his bizarre, alcoholic parents. When they learned their son was having difficulty, the parents created a scene in the administration building, with the mother proclaiming that she "had modelled her entire life after Tammy Faye Bakker". (This happened before the PTL scandal, of course.)

Remember abuse of alcohol and illegal drugs as a factor in medical school failure, but do not assume this is the underlying cause. Students abusing alcohol or using illegal drugs rarely fail their course work , and at least one current study from Harvard concludes that school stress and emotional problems "are more likely to be causes rather than consequences of drug use."

Anecdote 17: A medical student turned in an unusually poor performance on the pre-Christmas final exam, and had a mean corpuscular volume of 110 fL when students checked their own blood in the author's pathology course in mid-January. Confronted with the lab result by the author, the student confessed that his wife had left him in mid-December and he had spent the holidays drunk. After the appropriate referrals, the student did well.

Anecdote 18: A student in the accelerated medical program at Brown who lived in the author's dorm was drunk almost continuously for a semester and earned failing grades in his courses. He was dropped from the medical program, but was allowed to return to college. Afterwards he told the author he had never been interested in medicine.

Remember that a few students fail because they do not want to be in medical school in the first place.

Anecdote 19: A medical student at East Tennessee had a record of overall performance far below that of his classmates. Upon failing a major examination, he indicated he had never wanted to be a physician, but was forced to attend medical school by his parents. He withdrew from school and appeared very happy about his decision.

It is also conceivable that some students cannot do the work because of inherent lack of ability. Hopefully this is a diagnosis of exclusion. The medical literature has begun talking once again about students who have "insufficient intellectual ability." Some medical students may have been accepted for political reasons or even by fraud, though we have no data to support this. There is little that we would be able to do for such students.

Despite the wide range of emotional and situational problems that can interfere with the performance of an otherwise-qualified medical student, a wealth of studies indicate that the prognosis is generally good provided the student accepts treatment for a specific disorder. Of course, this is best handled by a specialist.

2. The most common reason for failure in medical school basic science is problems with learning techniques. These students can be identified and often helped.

Today's educational theorists emphasize the distinction between meaningful learning and rote leaning. "Rote learning" is the forced memorization about which weaker students complain so bitterly. "Meaningful learning" is whatever incorporates new knowledge into the learner's previous cognitive organization. The degree to which a learning experience is meaningful depends upon the learner's private framework of related concepts ("encoding"). We understand new ideas only when we relate them to what we already know. The key to helping the typical high-risk medical student is changing him or her from a rote learner to a reasoner and understander.

Anecdote 20: At the UMKC program for high-risk students from across the U.S., individual students are asked whether flattening a ball of clay will make it weigh more, less, or the same. Many students cannot answer this question. Those who can are asked to explain their reasoning. A typical answer is, "The clay weighs the same because neither kinetic nor potential energy is changed." The organic chemistry course is the traditional ordeal that determines whether a college student is medical school material. It is a good choice. Organic chemistry is easy to learn if the student understands its essential principles, and almost impossible to learn if approached as a rote memory task. A few students do pass "organic" using their fantastic memories, only to have their powers finally exceeded by the demands of the introductory course in anatomy, physiology, or pathology.

All the techniques used to help the class generally -- giving clear learning objectives, making students use and integrate their new knowledge in lab, providing fair and timely evaluations, and forcing the students to keep up with the material by examination strategy -- are doubly helpful to the high-risk student. Combined, the student has every opportunity to understand and remember, rather then to memorize and forget. In a well-run course, the high-risk student is the one who still tries to memorize without understanding.

In addition to obvious poor performance in lab and on exams, several other behaviors should alert you to the student who is not understanding.

Students who do not try to understand remain passive during lecture. An experienced lecturer can identify the high-risk students almost immediately. Certain students say they "like to sit back and listen during lecture to get the big picture." These students do poorly, because effective learning is never passive. The good students are continually thinking of questions and paraphrasing the lecturer's statements in their personal notes (even when there is a "comprehensive handout"), thereby testing their understanding and interrupting the lecture if they are lost. (It is a mistake to tell students to "hold all questions until the end." It is much better to handle all reasonable questions as they arise.) If passive students learn the skill of processing information during lecture, they are well on their way to becoming successful students. (Students who actually do not attend a good lecture are asking to fail.)

When students come to you with learning problems, ask to see their textbook and notebooks. If the student takes no notes during a lecture, or "relies on the class notes", he or she needs immediate instruction on the importance of learning actively. If a large percentage of a weak student's notes, handouts, or textbook is highlighted (often in many colors -- the "rainbow notes" syndrome), he or she is trying to memorize facts before understanding the big picture. (Look at how emphasis is used. Some very effective students use different colors to distinguish different kinds of information -- gross, microscopic, clinical, current research.) If there are few or no sketches among notes, the student is relying on verbal associations. Some students transcribe whole lecture tapes, or copy text or notes verbatim in an attempt to burn the words into their memories. This is the worst approach to learning, and will end in disaster sooner or later.

Next, ask the student to show you how he or she studies new material. A student who attacks a textbook chapter without previewing the pictures and captions has never really learned the importance of identifying major ideas quickly. A student who reads without taking notes or without making any marks in the textbook is reading passively and will learn very little. Ask whether the student uses a forced recall-paraphrase technique in learning. Effective students stop after each paragraph of text or notes and repeat what they can remember in their own words. If a high-risk student claims to be doing this, ask for a demonstration. You will simply hear word associations. Ask the student how much time he or she spends reviewing each subject daily. This is when relationships among ideas become clearer, and it should be a regular practice. However many high-risk students spend excessive time reviewing material they already know, because it makes them feel better. Finally, ask whether the student studies with music playing. Everyone knows that music is a potent distraction, and studying to music is at best a bad habit. I always suspect that a student who studies next to a radio is either not serious about school in the first place, or is using music to ease the agony of doing an impossible memory task.

The author uses concept mapping to force understanding among high-risk students. This technique, introduced in the early 1980's, is now widely used at the grammar school and high school levels. It was designed to teach young children how ideas are inter-related, but even at the medical school level, it leads to speedy mastery of key concepts. The technique was designed to "extend, modify, and elaborate these concepts partly through providing instruction in new relationships among the concepts that the student already has and partly by providing new relevant concepts about learning."

The concept map is a hierarchical, progressively differentiated, clearly integrated construction in which concepts (written inside ovals) are linked by logical connectors (arrows with words describing relationships). The more complex the map, the better relationships are displayed.

Medical school basic science teaching lends itself especially well to the concept mapping technique, especially in physiology, biochemistry, and pathology. First, the teacher's concept maps provide a focus for discussion sessions when students are required to relate facts to one another. At the beginning of the year, I sketch a map as students think of "different things that cause shortness of breath", or whatever. Two of my maps are included in Appendix II. [Online visitors: Sorry, these aren't available. Click here for a sample concept map variant, this one teacher-generated.] Later, the group must generate its own maps.

Once the class has seen the technique, I tell all students in difficulty to make concept maps and let me see them. Making the maps forces all students to see the discipline as an integrated body of knowledge rather than as isolated facts to be regurgitated. Typically, students who reject the technique continue to have major difficulty, while students who use the technique exhibit striking improvements.

Denial is the major defense mechanism used by students who are not understanding, and it is the major obstacle as you try to help. One recent study identified a large sub-group of medical students who do not realize when they do not understand something. Like most high- risk students, the subgroup not only does not understand, but also seem to be incapable of developing insight into this fact. According to the author, these students "have a chronic problem in their unawareness of cognitive weaknesses. The gravity of graduating such students without considerable correction is self-evident." But the author reports a poor prognosis for these students despite efforts at correction.

Hard data are lacking, but my impression is that poor learning techniques cause much of the "anxiety" and "depression" that are in turn blamed for causing poor performance. However, once the emotional turmoil of failure begins, a vicious cycle is created, which can only be broken by you, the teacher.

What do you do for the high-risk student who is a memorizer rather than an understander? In my opinion, all these students deserve expert coaching in learning skills, and most should delay the study of medical school basic science until their learning skills are adequate. If possible, allow them to "withdraw while passing." It is a tragedy for these talented students to endure the stigma of academic failure. It is equally tragic to allow them to enter their clinical years poorly equipped to understand disease. By helping these students change from "memorizers" to "understanders", you have equipped them for lifelong meaningful learning.

-- Ed Friedlander, M.D.

This paper was originally prepared for the Association of Pathology Chairmen.

Without the guidance of my brother, education expert David Gillespie, my students would still be hanging me in effigy. Thanks also to UMKC's Dr. Robert Blanc for helpful discussions, and especially for his anecdotes about clay balls and reasoning processes.


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