The generational shift in the learning styles of medical students

recent survey published in H&P, the Stanford medical school magazine, asked twenty graduating students to recommend books to read during the clinical rotation in internal medicine. Surprisingly, the top vote-getters weren’t books at all. The two most popular resources were both banks of practice questions, while the next two included a review book and a pocket handbook.

“Is this how our students learn the subtleties of sickness and health? What happened to textbooks? We had to read Harrison’s Principles of Internal Medicine cover to cover!” remarked one professor after reading the survey.

For what it’s worth, Harrison’s did receive one vote in the survey. But the results reveal a profound generational change in how medical students are learning the fundamentals of human health and disease. The recent explosion of printed and digital resources offers students alternatives to the classic texts that previous generation swore by. As a result, medical tomes are no longer the primary means by which students learn medicine, but just one piece of an increasingly complex puzzle.

Medical school is often compared to drinking from a fire hose; the student’s job is to imbibe as much knowledge as possible without getting bowled over. This is not a new phenomenon. Western physicians have been producing vast compendia of knowledge for millennia. The ancient Greek physician Galen published hundreds of treatises, aided by an army of scribes and students who recorded his every word while he saw patients.

The modern academic physician also leads an entourage of student doctors during daily rounds. But instead of scribing away on scrolls or stone tablets, today’s trainees scroll through their web browser on tablet devices. While one resident looks up drug dosing on UpToDate, her colleague consults Diagnosaurus to make sure he didn’t miss anything in the differential diagnosis. Meanwhile, the medical student quickly does a practice question on the USMLE World online question bank to test if he really understands the treatment algorithm.

The shift away from voluminous texts starts early in medical school, when the first exams come up before any of us has made it all the way through Gray’s Anatomy. Students opt for streamlined review books and digital resources in part because they are, well, streamlined and digital. Instead of reading about each step in the Krebs cycle, download an app with vivid pictures and animations. Instead of lugging a cardiology textbook to the library, go for a run while listening to a podcast about congestive heart failure. And if Google doesn’t have the answer, consult the online version of Robbins Pathology (soon to be powered by Google).

Students also point out that reading textbooks is “passive learning,” which many studies have shown to be less effective than “active learning” such as answering quiz questions. Others may want to tailor resources to their individual learning styles; visual learners frequent websites like SketchyMedicine and Picmonic, audiophiles stock up on lectures from iTunes U. Medical schools (including Stanford) even collaborate with web-based platforms like Khan Academy to digitize their curriculum.

The generational shift in learning styles is a source of consternation to at least a few senior physicians. I recall one clinician who helped us examine a patient in respiratory distress and then quipped, “There is NOT an app for that.” In another instance, an exasperated consultant asked a resident, “Do I need to draw you a picture?!” — and was shocked when the resident replied (without a hint of sarcasm), “That would be great; I’m really a visual learner.”

I have also heard faculty say that trainees must “earn it to learn it.” Wading through Robbins and Harrison’s makes students confront the sheer depth and breadth of medical knowledge, and ultimately imparts a more nuanced understanding of human disease. As one surgery faculty put it, “would you really want your life in the hands of a doctor who aced his multiple-choice boards questions but hasn’t read a textbook?”

The truth is likely somewhere in between. Innovative digital resources are vital for helping students retain knowledge and simplify difficult concepts. As long as there are multiple-choice board exams, there will be demand for streamlined review books that distill high-yield content. But Harrison’s isn’t going away anytime soon, nor should it. There will always be a need for textbooks to provide comprehensive information. And even the most committed app aficionados among us will eventually make it through those books – just maybe not during internal medicine rotation.

Mihir Gupta is a medical student who blogs at Scope, where this article originally appeared.

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  • guest

    As a teaching attending, I have noticed this phenomenon myself. I do not necessarily see it as a bad thing, but I think there are a couple of caveats for medical students (and residents) to keep in mind.

    The first is that almost all of the learning resources mentioned above present a less integrated, more fragmented approach to medical knowledge than reading through a textbook chapter or a good review article. There is a certain amount of neuroscientific evidence that learning is most effective when there is a larger contextual framework on which to “pin” the facts the learner is trying to remember.

    The second is that the medical student who is using “downtime” on rounds and on the units to sneak in practice questions here and there “to test his understanding,” is frequently missing the opportunity to hear or see something important about the patient, or that the attending has to say. After all, a doctor who aces his board or shelf exams but has not learned the habit of paying close attention to the details of his patient’s history and condition, will never be a good doctor. I would recommend that everyone read this very fine piece by another medical student…

  • Dave

    A big driving force behind this is the NBME (national board that writes exams med students take after clinical rotations; also write the licensing exams all MDs must take) which, as any student will tell you, tests minutiae more than concept. While many of the test questions can be answered with the framework provided by Harrisons et al, the difference between pass/high pass/honors is largely determined by minutiae. The digital question banks and other resources are great at teaching this content and focusing on minutiae that NBME writers seem to like, and other review books can give enough of the conceptual framework to answer most of the other questions. It’s not hard to write a multiple choice question that requires conceptual knowledge and clinical reasoning, but until the NBME/USMLE makes such questions the bulk of their exams, students will continue to focus on what they need to know to score well and advance in their careers. The top students in any school are already balancing clinical duties, ongoing research, leadership in student organizations, off-campus service work, travel to national meetings, networking, and maintaining their sanity. With only 2-3 hours per day x6-12 weeks (depends on school) to study for any given shelf, junior students simply don’t have time for reading a giant tome that doesn’t reflect what’s truly tested. Even if they wanted do, that’s 35-70 large pages per day.

  • Margalit Gur-Arie

    I honestly am not trying to be disrespectful here, but if all you do with the “fire hose” is train yourselves to hop through apps looking for ready-made quick answers from various software programs, then the tech entrepreneurs inssisting that doctors can easily be replaced by computers are starting to make perfect sense.
    And BTW, this is not unique to medical school. From a very young age, kids today are conditioned to search for (google v.) answers, instead of going to the enormous trouble of mastering the fundamentals and training their minds to independently analyze and God forbid come up with an original idea that was not already provided by a “thought leader” and properly indexed by Google.

  • brettmd

    Sometimes I find listening to articles useful. One may be able to listen to a chapter of Harrison’s through this app.!-text-to-speech/id308629295?mt=8 In order to listen to a book chapter.


    Supplementary information:

    If listening to the references is unpleasant or disruptive,

    1. Copy the chapter text from the book’s webpage, such as Ovid and paste it into a Microsoft Word document

    2. Go to top right of Document,

    3. Click Select, a drop down menu will appear

    4. Select from the upper right corner “select text with similar formatting”

    5. Select & copy text without the citation eg. ADAs may neutralize the efficacy of the biologic [1,7,9].

    6. Open a new Microsoft Word Document

    7. Paste the following ADAs may neutralize the efficacy of the biologic

    8. Email yourself the text

    9. Paste the text into speak it app.

    • Dave

      Wow, what a great idea! I did a word count on some Harrisons chapters and they seem to hover around 15,000 words. Most books on tape voiceovers are at ~160 wpm so at that rate you could do a chapter of Harrison in 94 minutes. That would fit nicely into a workout or commute. I’m going to have to give that a try for articles too – definitely don’t read as much as I’d like. Thank you for the idea!

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