No anesthesia resident left behind

At a recent faculty meeting, we learned that the first year residents in anesthesia will now have to take and pass a written exam at the end of their first year.  They will have a certain number of tries and if a resident can’t pass it by the third try they’re either out of the program or held back in some way.

Now, it used to be when I was a baby resident that the first year residents took the certification exam that the third years took, and it was graded on a curve based on year.  You didn’t have to pass it or get a certain grade: it was sort of a reality check, to see how you were doing.  I don’t know who’s brilliant idea this new test was, other than the people who administer and charge for the test.  It might be a solution in search of a problem, I have no idea.

Here’s the thing.  Testing freaks residents out.  They have been taking high stakes tests their whole entire lives.  In high school they had to get As and score a 1400 on the SAT.  In college they still had to get As, but also had to ace the MCAT.  In med school the tests might have been pass/fail but USMLE Steps 1 and 2, both of which are taken during med school, certainly weren’t.  Results of those had bearing on what residency you got into.  The result of all this standardized testing is that every resident has PTSD about tests, and every resident has had years to figure out how he or she can most quickly cram in the amount of information necessary to do well on the test.  Residents are masters of this.  There is absolutely no reason to read the textbook, which is likely 8 years out of date anyway, when you can go straight to the review books and practice exams online.  Especially if the threat of expulsion or repetition, both of which are disasters on multiple foreign and domestic fronts, is held over their heads.

Cramming for a test is not learning.  Let me make that perfectly clear.  You forget it the minute you walk out of the exam room.  Learning facts and passing multiple choice exams is not learning.  It is not necessary to understand a subject to do well on it on tests.  Prime example: me in calculus.  I had no idea what I was doing or what it meant but I knew if I memorized how to run the steps I could always get the answer right.  It was hilarious in a really sad way that I didn’t appreciate at the time.

Medical students and residents are not lazy learners.  Given the right incentive they want to understand the material.  But they also know two very important facts:

1. Most of the facts are not necessary to clinical functioning.  A lot of the questions asked are about things you never actually use in practice.  Everybody knows the dweeb who aces the exam but is completely hopeless in the clinic.  Conversely you can have a great clinician who somehow managed to make it this far without knowing the partition coefficient of Sevoflurane.

2. The most important thing is always what the people in power think of you.  The system is rigged so that passing the exams substitutes for more in depth and complicated evaluations.  A great exam result is likely to get you off the hook for practical failings.

This new test will likely result in all first year anesthesia residents freaking out.  They will haul around review books, new ones that have generated a lot of money for the people who write those things.  They will look sidelong at their friends to see who is studying more than who or who knows more esoteric facts.  They will stay up late and yawn in the OR.  Study groups will form.  Marriages will falter.  Children will go unfed.  And once the exam is over, nothing will have changed.  Their skills will be the same.  They will have been learning facts in place of learning how to give anesthesia.

Shirie Leng is an anesthesiologist who blogs at medicine for real.

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  • Ron Smith

    I admit when I first saw this post title, I didn’t think there was anything that was applicable to me. Now I see that this hits home with something that I think is fundamentally flawed in medical training. I never hear anything about it.

    The problem with training, I think, is the lack of apprenticeship.

    Adequate training is founded, so the current thought is, on these endless series of tests. I mean I’ve been practicing Pediatrics for 30 years and have taken the stupid boards till I’m sick of them. When is enough enough? I mean I pass them every time and now we have ever continuing process of constantly being boarded!

    The reason that we use testing instead of apprenticeship is pure and simple. Its medical slothfulness. Apprenticeship takes time and participation of both the instructor and the student. The determining factor that the student understands the subject. The instructor clearly knows what the student understands.

    How can written testing even come close to producing the clinically superior medical practitioner that apprenticeship does?

    My residency program in Pediatrics at Oklahoma University Tulsa Medical College was heavily community based. That is, most of my instructors were Pediatricians in real practice. Half of our patients were actually their patients. We had to learn. There was no faking it.

    That education is priceless to me and has served me well these three decades.

    Education today seems to just be chasing more and more testing and less and less clinical apprenticeship. I’m a clinical associate professor at Mercer Dept of Pediatrics. I volunteered to take time out of my busy schedule. Since they accepted me over two years ago, I have yet to see the first resident darken my doors. I like to teach. I want residents to also learn the business of medicine. I’m solo and my practice is thriving.

    You might think that primary care Pediatrics is boring. Here’s a list of some of the diseases I’ve seen in just the last ten years or so.

    1. optic toxoplasmosis (2 cases who were sisters) – 24 cases reported worldwide last I heard
    2. CH50 deficiency – 1 in 2 million
    3. hypoplastic left heart (he just graduated high school)

    4. Spasmus nutans
    5. Long QT type 3
    6. diaphragmatic hernia into the pericardium (Hernia of Morgagni)
    7. and I could go on…

    As a private solo Pediatrician I was involved with the last clinical research on Exosurf, an artificial lung surfactant that changed the dreary thirty percent premie mortality over thirty years ago.

    Both clinically and educationally, I have a lot to offer!.

    The point that I’m making here is that testing cannot alone produce the kinds of clinically superior professionals I think we need. Only apprenticeship can do that.

    Warmest regards

    Ron Smith, MD
    Pediatrics

    P.S. I’m solo in McDonough Georgia doing primary care Pediatrics (a full load) and itching to teach. Look me up. My web site is my name: ronsmithmd (dot) com.

    P.S.S. Oh and no one was there to relieve me this week because I worked to many hours, so please pardon any spelling or grammar errors. I’m a little tired.

    • Elvish

      “”The reason that we use testing instead of apprenticeship is pure and simple. Its medical slothfulness. Apprenticeship takes time and participation of both the instructor and the student.”"

      Well said doctor. There was a time when some good doctors were good because they were trained under “Dr.xyz” and he was the best in his field. Nowadays, they pass a test with a relatively higher score and they are considered good.
      As a matter of fact, apprenticeship is the only way to learn the art of our profession.

      • Allison Falin

        I would agree, but with the “good” doctors leaving the profession, how would you propose people gain their apprenticeship? While I am a FNP, it was absolutely incredibly difficult to intern with physicians due to a lack of MDs willing to teach. I was very blessed to work with 3 of the best MDs in their field where we were, but it took a lot of persuading on my part and graciousness on theirs.

  • Dan Schwartz

    Would YOU drive over a bridge in which the Engineer who designed it believed 2+2=5?

    Well, the LAST thing I want to do is look up in the operating room and see Dr Shirie Leng as my anesthesiologist…

  • ninguem

    “…..At a recent faculty meeting, we learned that the first year residents in
    anesthesia will now have to take and pass a written exam at the end of
    their first year. They will have a certain number of tries and if a
    resident can’t pass it by the third try they’re either out of the
    program or held back in some way……”

    Isn’t that the “in-training exam” that’s been going on…….for decades?

    Are you describing something new?

    It exists in all the training programs, anesthesia, primary care, probably most if not all specialties.

    In the past, I don’t think failing the in-training exam got you thrown out per se, but if combined with poor performance overall, you were asked to repeat a year, or were dismissed from the program.

    In real life, usually poor “in-training exam” performance went hand-in-hand with poor performance overall, though not always I suppose.

    • Dreamcatcher

      It is not the ITE, but part 1 of written boards. We will take part 2 (advanced) at the end of training along with the oral boards.

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