At first glance, Step 1, which emphasizes basic science knowledge and is taken after the second year of medical school, would seem necessary to insure that medical students have achieved the proper level of knowledge to proceed in their education. However, there is another consideration.
I cannot help but notice the great amount of time spent by students discussing how to pass the medical Boards; students are compelled to spend a great deal of time in rote memorization of esoteria for the exam; otherwise they may not pass. In my view, this emphasis interferes with the need for students to acquire a proper understanding of the topics discussed in the first two years, understanding that is vital in taking care of patients.
Today, it is relatively easy to electronically search for isolated points of information through apps and the Internet; there is less need for rote memorization, which computers do best, and greater need for understanding, which humans do best. Despite the information explosion, surely there is less need to memorize so much and greater need to promote understanding of the clinical material as a whole.
Even the best physicians may have trouble with questions on the Boards. We would like to gear medical education to turning out the best physicians. But what constitutes an excellent physician?:
• Most cases a physician sees are common situations rather than zebras. Good medicine is largely a matter of applying common knowledge and principles to diagnosis and treatment, without getting sloppy, rather than coming up with a roundsmanship coup. The excellent physician does not, to save time, routinely order, in a shotgun fashion, all manner of rare, invasive, and expensive low-yield tests. Nor does the excellent physician hastily rush to decide on a diagnosis based on a too-quick, superficial initial impression. The best physician is not necessarily the one who has the greatest knowledge base, but the one who consistently and meticulously applies common knowledge.
• Patients do not care so much about the physician’s medical school or residency diplomas as they do care about how the physician responds to them as individuals, whether the physician is compassionate, and allots the patient the necessary time. “Patients do not care how much you know, until they know how much you care.” This aspect of medicine is also important, just as is the knowledge base.
• The good physician, unless there is an emergency, schedules reasonable office waiting times, promptly notifies patients of lab results, follows up on the patient’s progress, and adopts more than just a cookbook approach to diagnosis and treatment. Medical education needs to emphasize understanding of important concepts, as well as familiarity with where and how to search for isolated points of information, which have grown too large for anyone to remember. This is not emphasized on the Boards. Emphasizing understanding, something Medmaster has focused on for the past 34 years, may seem to be a minimalistic approach to education, but in fact it is a maximal approach, insuring that the student acquires the greatest degree of understanding. Every patient is different, and a cookbook approach may not work for all patients; understanding what one is doing is critical to good patient care.
So, should Step 1 of the USMLE be eliminated, or modified? Perhaps Step 1 should be an open-book exam; this would more resemble everyday practice, where physicians now have ready access to point-of-care information. What do you think?
Medical student forums extensively discuss study for the USMLE exams. While this is important, because you need to pass the exam, there is a problem with spending a lot of time on rote memorization of numerous facts, since it steals time from understanding the subjects.
Understanding is key to practicing medicine; it enables the physician to provide better individualized patient care than relying on rote cookbook facts. Understanding also facilitates memory and retention. For those of you who have taken large subjects such as Biochemistry or Physiology, have you at the end acquired a broad understanding of the fields, or are you left with isolated points that never quite gelled into a coherent whole?
There is a better approach to medical education than rote memorization of an impossible number of facts. The medical school curriculum should instead insure that the student gains an overall picture and understanding of each subject, rather than cramming in an overbearing number of facts that will later be forgotten, even by the best physicians. These days, it is relatively easy to find isolated points on the Internet and elsewhere. It is not as necessary to remember everything; computers do a better job at that. The USMLE should also focus on understanding, but students are still required to memorize tons of information.
Over the past 32 years, Medmaster has tried to assist medical education by focusing on understanding, rather than rote memorization, through brief, clinically relevant books.
Since one has to study for the USMLE, it is important to maximize the efficiency of study, so that a great deal of material can be reviewed and retained in a short time. Andreas Carl has written Medmaster books for the USMLE Step 1, USMLE Step 2, USMLE Step 3, and NCLEX-RN exams using a unique approach. Rather than just presenting isolated and unrelated points, he has made extensive use of charts that compare one point with related ones; this saves study time. For instance, the chart below compares the most common causes of infection. Apart from having few words, the chart quickly allows the comparison of one disease with another. All his books do the same. His supplementary USMLE and NCLEX-RN Question Banks (available as free downloads from the Medmaster website), make review quicker by combining a number of questions into one, so that 4 or 5 facts can be covered in the time that it ordinarily would take to cover one.