In recent years, there has been a push across medical schools to change the grading scale towards that of a pass-fail system. The appeals of a pass-fail system to me were obvious. Instead of worrying about my grades as I had in college to maintain an adequate enough GPA to get into medical school, I believed that merely passing would lessen much of the pressures I faced as an undergrad.
Those romantic notions about the medical school academic experience were quickly eviscerated on the first day of class, when I came to comprehend the formidable degree of volume we were expected to learn on a daily basis. We were learning a semester’s worth of material in a single week. The facts piled on themselves. The pace unrelenting. I studied harder for my first medical school exam than I had ever before in my life, and I barely walked away with a passing score.
And yet passing at the beginning of medical school was enough. We were being tested on basic science concepts that did not yet hold much direct clinical application. In anatomy, we were learning Latin on the fly and where different bones and muscles and nerves and blood vessels were in our bodies. While the information was interesting, I still was unable to correlate what we were learning to patient care yet. And as such, taking biochemistry and anatomy exams felt removed from the lives of real people. I felt OK just passing. The exams did not hold much weight beyond me personally being able to continue my status as a medical student and not failing out.
Things changed when we started learning physiology. We were moving beyond just what the heart and the lungs were and where they were into how they actually work. It also turns out that major disease processes are much more interdependent with how our organs work rather than what they look like. As such, the material that we were learning in physiology could immediately be tied to common medical conditions. In learning cardiology, we were also learning the basis of heart attacks and arrhythmia. In learning pulmonology, we were also learning the mechanisms of emphysema and asthma.
These diseases were not just theoretical thought exercises, but real conditions afflicting real people, including family members and family friends. I began devoting myself to my studies with a greater vigor. Towards the end of my cardiology unit, I could explain to my grandfather why his doctor had prescribed him beta-blockers for his irregular heart beat. By the end of my pulmonology block, I would explain to my grandmother what her emphysema was and why she would need to take a beta-2 agonist for her condition. It frustrated me that her physicians hadn’t done what seemed to me as a basic duty educating their patients, but this was now an opportunity for me now as medical student to really apply what I was learning to help people I cared about.
I felt ready and excited going into my physiology exams. And yet, despite my enthusiasm and added drive, the exams were no easier than the ones I took at the beginning of the year. Rather, they were even more difficult.
And then I finally failed my first exam as a medical student, in renal physiology.
I felt a real sense of guilt. The questions that were asked of us in physiology were cases in which patients present with real symptoms and conditions seeking help. During the exam, I was too locked in and too rushed on time to think beyond just solving the problem at hand, but in stepping back after the exam, I could sense the gravity that these case-based questions carried.
Although I am only a first-year medical student, I know that in a real-life situation, should I have gotten one of these questions wrong, I could have misdiagnosed one of my patients, I could have given my patient the wrong medication. That sense of guilt was a stronger negative reaction than any of the personal frustrations and exhaustion I felt studying for the exam. Even though this was only a written exam, I wasn’t just letting myself down; I felt like I was letting my future patients down.
Medical school was no longer like any form of education I had undergone earlier in my life where only my future would be affected by my academic performance. Now my competence would also affect the lives of others.
The next day, classes started again, commencing yet another unit in medical school. There was no time to dwell on the past exam. There was no time to waver. I had to pick myself up. I had to refine my resolve. Medical school was moving forward as was I.
As time has passed, I have come to realize this will not be the last time I will make such a mistake. No matter how hard I study or how hard I work, no matter how good my intentions are, I will still make mistakes. Indeed, it’s continued to happen every subsequent exam. And each time, I still move forward. My strength builds.
Perhaps the unintended meaning behind our pass-fail system is to teach us how to forgive ourselves. There are limits to my talent and limits to my abilities. I will continue to be made painfully aware of those limitations again and again in my career. Even with all of our education and advances, with our training and our technology, those of us working in medicine are ultimately human – as human as the patients we seek to treat and care for. And when I am in the clinic no longer taking multiple-choice exams, but working with real people, I will still make mistakes during my training. Patients may not get better. They may not respond well to our treatment plans. And yes, they may die under our care.
When that day comes, it’s going to be hard. It will hurt, just as it did this time when I failed a medical school exam. I bet it will hurt me more. It should.
But when that day comes, I’ll also find that firmness of will to keep myself going, to do better for the next patient, for the next family. I’ll press on. It’s not going to be easy, and it’s going to take time, but I will continue to get better at this. I’m going to press on.
Johnathan Yao is a medical student.
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