Skip to main content

Should medical board exams be open book?

Janet Smaller

“The problem with medical school is the Krebs Cycle.”

This is a common refrain from physicians. More precisely, the problem is rote memorization of the Krebs cycle, other metabolic pathways and seemingly useless facts.

With medical knowledge doubling every 73 days, today’s students are learning diagnoses and treatments that could be out-of-date before they enter residency. The Step 1 boards incentivize quick recall with their rapid-fire, 300 questions-in-eight-hours format. And the only way most medical students can learn--and retain—the piles of information they hear in lectures and track in labs is through simple memorization.

But do students really understand the facts and figures they’re repeating? University of Utah Health biochemistry professor Janet Lindsley, Ph.D., wondered. Isn’t understanding how metabolism works, Lindsley thought, more important than parroting facts and figures?

In collaboration with colleagues at Sanford University and the University of California, San Francisco, Lindsley waded into a century of medical education dogma and suggested a simple idea: Why not provide a metabolic map as a resource for licensing exams?

The National Board of Medical Examiners agrees.

Editor's Note: Instead of focusing on curriculum design, we’re celebrating people who are already lifelong learners. They’ve taken on the responsibility to learn new skills and are helping create a system that supports that kind of learning for others. They’re changing the culture.

Q: What’s wrong with rote memorization?

A: There is so much content that students have to master to pass their licensing exams. Residency program directors use student scores to weed out candidates, and students know it; they know this test means everything.

What we want students to learn is not only based on facts; it’s based on how do you think about people and treat people and maintain your passion and develop leadership skills? But students are stuck having to learn so much content.

We can memorize information without being able to apply it and understand it. Metabolism is particularly complex, and we’ve memorized all this information without really being able to apply it. Even though I ended up with a Ph.D. in biochemistry, I don’t think I could have clearly explained why we need to breathe. That’s one of the most fundamental problems of biochemistry, but I could not explain it and I had a Ph.D. in the field.

Q: But providing resources can’t really cover everything medical students need to know. Is there still a place for memorization in medical education?

A: It’s at least a symbolic step to say, “We’re going to provide this to you. You’re going to need to be able to have the skills to interpret it.”

You’ve got to know some content to be able to think about what the questions are. There’s a lot of skill in appropriating the map. It’s a higher level of thinking to be able to utilize a map. It’s sort of a launching point. But you have to have a lot of information before you get to the launching point.

Q: Why go back to teaching?

A: I really hated running a lab. I had two [NIH] R01 grants funded and I said, “I don’t want to do this anymore.”

The part I liked was writing grant proposals, which is opposite of most normal people. What I really enjoy is the forced opportunity to sit down and make sure I understand something well enough to get someone else interested, and enthusiastic about it also. I preferred the big picture and the inter-relationships in science more than the deep nitty-gritty that’s required to run a research program. I didn’t think I could convince my friends, neighbors, and family to pay higher taxes for a research project that I didn’t believe in.

And getting tenure put me into a depression. It made me feel trapped. I’m grateful that I was given the latitude to find other ways to contribute to the mission of the University.

Q: What’s the best part of teaching?

A: At my core, I’m a scientist. Scientists love change. They live at the intersection of the unknown. We love the fact that we don’t know everything. When a student asks a question, I can say, “I don’t have a clue and I don’t think anyone else has a clue. Somebody who’s bored, could you please look it up and get back to us?”

Q: How do you think students will learn in the future?

A: Technology and multimedia provide so many great opportunities for learning. However, not all important medical information is going to be made into cartoon videos for easy memorization. And I’m slightly scared that students will lose the ability to read difficult texts, because we don’t do it much anymore. There’s still going to be a need for physicians to read difficult material. Not everything’s on YouTube yet.

By: Rebecca Walsh

Rebecca Walsh is a Senior Writer for University of Utah Health Sciences.