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On the STATMed Podcast: Navigating Test-Taking on Medical Boards and In the Classroom

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Strategies for approaching test-taking on medical boards the STATMed way

It goes without saying that a lot rides on your medical board exams. And before you even get to the point of taking the COMLEX, NAVLE, (or the exam for your field), you have to pass your med school exams. That’s a lot of pressure, especially for self-professed bad test-takers

In this episode, host Ryan Orwig is back with Dr. Jim Culhane, Assistant Dean for Student Academic Success Programs and Professor of Pharmaceutical Sciences at Notre Dame of Maryland University School of Pharmacy. They dig into test-taking on medical boards and in the classroom. In part one of this two-part podcast, Dr. Culhane details the process of exam creation while Ryan shares STATMed’s meticulous approach to test-taking. 

“If you’re going to do the Boards Workshop, we’re not going to fix your test-taking. I’m not going to go in and plug holes. We’re going to tear your system down to the ground. We’re going to bulldoze that sucker and build in its place our very rigid, very meticulous system.” – Ryan Orwig

Are you struggling to prep for medical boards or in-class exams? We can help. Learn more about the STATMed Boards Test-Taking Workshop to get the most out of your study sessions.

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Transcript

Welcome to the STATMed podcast, where we teach you how to study in med school and how to pass board style exams. Your host is Ryan Orwig, a learning specialist who has over a decade of experience working with med students and physicians. In this two part episode, Ryan and Dr. Jim Culhane discuss test taking on medical boards and in the med school and PharmD classroom.

About natural phenomenon. And as science evolved over the centuries, we were able to prove and disprove some of that. And I think what’s so brilliant about what you’ve done here, at least from my perspective is that you’ve taken thousands and thousands of hours, right? Of observing medical students taking tests, the types of mistakes that they make and looking at questions, lots of board style questions, and really logically rationalizing out the system. It comes through very clearly when you’re taking this course.

Very, yeah. Really codify.

Hey, this is Ryan Orwig with STATMed learning podcast, where we talk about studying time management and test taking in med school, on medical board exams and in related fields like veterinary medicine and PharmD programs. Today, I’m going to talk about some specifically nuanced stuff about test taking with my friend, Jim Culhane. Jim, go ahead and introduce yourself.

Hi Ryan. Thanks again for having me on the podcast, for those of your listeners who haven’t heard me speak with you before, my name is Jim Culhane. I am assistant Dean for student academic success programs at Notre Dame, Maryland University School of Pharmacy. I’m also a professor of pharmacology and have been teaching in pharmacy education for 25 years.

Absolutely. And you and I talk a lot about just the science of reading and learning and how we can intervene with our med students, with our PharmD students, with our physicians, how we can intervene instructionally, and you and I have been talking for years about the study side of intervention. That’s how we met over 10 years ago. Me coming up to Baltimore, working with some of your pharmacy students, just trying to give enrichment and taking them through the various study methodologies that we really emphasized those in those early years, but just recently, you’ve sort of opened the doors to looking at some of my very dense, very meticulously set up test taking. And when I talk about test taking, I typically say, I only care about boards. The USMLE, the complex, specialty boards, subspecialty boards, the NAVLE for veterinarians and NAPLEX for PharmDs. That’s the primary point of emphasis when I talk about test taking, but we do lay out a blueprint for those in the classroom years. I’ve given that blueprint to the pharmacy students up at your program and all of my med students. First, second years, we do lay out this blueprint for test taking, and that’s what you’ve done a deep dive into the STATMed test taking world, which I guess I just sort of taken for granted. You knew about all this stuff for the last 10 years, but this degree of depth that you’re climbing out of right now is all kind of new, right?

Yes. Very, very new. So as you pointed out, we’ve known each other for 10 or 11 years now, and most of our conversations and interactions have really revolved around study methodology and productivity management, things like that. A big part of my job here at Notre Dame is as an academic coach and to provide those types of services. Your methodology has been a real inspiration to me in terms of how I approach helping struggling students academically, and also a big inspiration for my upcoming book That’s gonna be released this year.

Go ahead and give us a little a quick…. We’ll do a podcast on that specifically, but go ahead and give us a quick little blurb on that.

Yeah, just very quickly. The books titled “Evidence Based Learning Strategies “for Pharmacy Students.” It’s gonna be published through the American Pharmacist Association. It’s a book that’s really written for pharmacy students. A lot of the examples that I use and the context that I write in is pharmacy education related, but I think it’s very accessible to other types of healthcare providers. And it’s really based around the book itself. And the approaches are really based around evidence based learning and study strategies that I pulled out of the literature and that have been developed and studied by cognitive and educational psychologists. So really excited about that.

Yeah, it’s amazing accomplishment.

I’m looking forward to talking to you about it when it comes out.

Yeah, it’s amazing accomplishment. And just I would say anyone who has looked at like books, like “Make It Stick” which is if you’re looking for the singular best book to read on learning science, read, “Make It Stick.” But I think what you’ve done is you then took a lot of those insights and lessons and aggregated sets of information and operationalize it into how to study.

Yeah, that’s the big thing. Yeah, you could talk about educational theory with students, but if they don’t know how to apply it practically day to day, it’s not much use to them.

No, no. And I think that if it applies to a PharmD student, it would work for a med student, it would work for physicians and people in related field. Anyway, now return the corner.

Yeah. So now I’m experiencing a whole different side of the STATMed program here, which has been fascinating. You’ve talked to me on and off over the years about snippets and little different components about what you do here, in your board’s workshop class and how you teach students to approach board style case vignette questions. And it’s always been something that I’ve been interested in, as an educator, right? I’ve been in higher ed for 25 years. I do a ton of exam question writing and administering exams and grading exams, helping students prepare for exams. So really seeing the approach that you’ve developed to help your medical students and clients to navigate these types of board style questions, it’s just been amazing. I am blown away by the thoughtfulness of this methodology, the use of critical thinking skills, it just oozes out of this in terms of how do you in a very step wise structured way using critical thinking logic and rational thinking, and with just even partial knowledge of the topic that you’re being tested on, you can get questions right that you normally wouldn’t if you just started reading from the first line or sentence of the question, and then go on to the answers, A, B, C, D, and E like most students do. It’s amazing. In fact, I think I was even telling you too, as I was working through unit two, and this is where you start to introduce how to actually use the method. And there’s some practice case vignette questions. I have a PhD in pharmacology, my undergraduate degree is in chemistry. So I’m not a medical provider. I’m not a physician. I’m not even a pharmacist. The only medical healthcare provider thing that I’ve ever done is I was an EMT and a combat medic for many years. But other than that, I really have no knowledge in that area. I was able to use the approach that you’ve developed to get the vast majority of those practice questions correct. Just with partial knowledge, I’m familiar with some of the diseases or drugs and things like that, that you introduce there. But to treat a patient, that’s just not what I do. And even if I didn’t get the question right, I was usually able to narrow it down to two possible answers. And if I picked the wrong one, it was only because of just my lack of knowledge, because I’m not a healthcare provider. It was a clean miss for me when I missed those questions.

Yeah. Right. Well, there’s a lot of things to respond to on that.

Yeah. Right.

The board’s workshop, that’s our test taking platform for the self-identified bad test taker at the medical boards level, USMLE complex, NAVLE, NAPLEX, specialty board, subspecialty board, etcetera. And the first two units are on demand. I think they’re about three hours combined, maybe close to four hours.

Yes about three hours.

Three hours combined for unit one, which is the process, which is a meticulous, granular step by step by step process for reading the question. Yeah I’m a reading and learning specialist. I’ve never been in the shoes of the struggling test taker for their medical boards, but I have some weird powers of empathy, but I know what it’s like to go to an expert and you can tell they know what they want you to do, but the way to communicate it to you is insufficient or incomplete.

Yes.

Go to physical therapy. Like if I’m going to physical therapy after I had back surgery, I just felt like the stuff I was being given, there were too many gaps and too many vagaries. I wanted it meticulous. So I tell people, I don’t know if I say this in the video or not, Jim. I say, if you’re gonna do the board’s workshop, we’re not gonna fix your test taking, once I identify that they’re a good fit. I’m not gonna go in and plug holes. I say, we’re gonna tear your system down to the ground. We are gonna bulldoze that sucker and rebuild in its place our very rigid, very meticulous system.

Yeah. And it was interesting. You do say that at the beginning. And I don’t know that I really fully internalized that until we started going through some of these practice questions, right? You went through the whole process very step by step, very detailed. But it would made a lot of sense. It’s not hard to understands. Right, but what was really interesting was when I started to do the first practice question, I immediately caught myself reverting back to my old student mode where I started at the beginning. I had to remind myself each time. This is step one. This is step two. And when I did that, I kept thinking to myself, holy smokes, if I’d have met you 30 years ago.

Yeah. 30 years ago we were probably both running close to being in Morgantown, West Virginia.

Yeah. I was there.

I would not have been of much help, but you’re right. A different version of me of course.

If I had met your current self 30 years ago. I think I could have avoided a lot of definite difficulty.

Yeah. Well, that’s what a lot of people say. A lot of people are like, I wish I found you sooner, but I’m like, look, we’re making this up. We are building this, cutting this out of the whole cloth. And it’s from observing and on the one side, the literature on learning, but the literature on the test taking is not anything to write home about. You can attest to that I think.

It really isn’t. And I think that’s one of the things that from my approach to a lot of these things and it comes because I’m an educator and a scientist, I’m trained as a scientist. I always wanna go to the primary literature and see what’s been done, right?

Yeah.

Where’s the evidence. Where do the studies point to? We’re not looking at single studies, a single study, but what do multiple studies over multiple years by different investigators, What does that tell us? That’s when you tend to get the best answers and they’re just with things like studying, right? You and I have talked about this in other podcasts, evidence based strategies, like active recall, or retrieval practice, interleaving, spacing. Those sorts of things, lot of good data for that. But with test taking, as I’m going through this module, I’m looking and nobody’s approaching it that I can find yet in the way that you are.

It’s pretty strange.

Yeah, and what really strikes me about your methodology too, is as I was experiencing it, I kept thinking of what you’ve been able to build here is very much, I think the approach that you took is very much like what the ancient Greek philosophers did. When they came up with atomic theory, there was no science as we know it at that time, but those folks were keen observers. They used empiricism, observing the world around them. They used logic, philosophy in order to break things down and draw conclusions about natural phenomenon. And as science evolved over the centuries, we were able to prove and disprove some of that. And I think what’s so brilliant about what you’ve done here, at least from my perspective is that you’ve taken thousands and thousands of hours of observing medical students taking tests, the types of mistakes that they make and looking at questions, lots of board style questions, and really logically rationalizing out the system. It comes through very clearly when you’re taking this course.

Yeah, really codifying, like these missed types that occur, we say usually one bad test, take’s probably gonna do three to five of the dozen or however many specific types we’ve identified. And they’re probably just doing them on an infinite loop because bad test taking is bad behavior. Like you said, you felt yourself being pulled back.

Yeah.

To your default settings. Those are gonna be there. We have to tear those down through self-reflection. And that builds what’s called self monitoring. We don’t even talk about that, that much in the workshop, but that’s what’s happening. It is behavioral modification.

You can see it. I’m getting into that part now. And I think you bring up something else that’s really interesting too. What is a bad test taker? ‘Cause you mentioned that a lot, especially in unit one. And I remember several days ago when I was going through that, I’m pausing, I’m going onto PubMed, I’m going onto the internet and I’m typing in, I’m trying to find, is there any literature out there about what characterizes a bad test taker? What characteristics do they have? And there are papers out there that talk about people test anxiety, which is a real thing.

That’s a thing. That’s very real, but that’s a different creature.

It’s a different thing, right? They talk about poor study exam preparation. Okay. Well we know that that’s an issue, right? But nobody that I’ve been able to find at this point has really, and maybe it’s out there. To be fair, I haven’t done an extensive literature search. But there aren’t things popping up there that say these are the five or six bad behaviors that students engage in that cause them to miss questions when they shouldn’t be. And I think you guys have done through observation, you’ve seen it and when you’re talking about it, again, I work with students every single day and I see them making these mistakes. So I know at least from my own experience that what you’re saying really resonates and there’s truth there.

Yeah. That’s what happens. These first two units that you’re walking through unit one is like the process, then unit two is like the greatest hits, collecting those mistypes and you’re modeling the behavior. You are giving feedback on decision making and then the solutions that go with each of the mistakes. And then the back half if you’ve got into that is where you take off your test taker hat and put on your test analyst hat. You take off the player hat and you put on the coach hat. One of the other important things we wanna think about with the bad behavior is behavior change and deliberate practice talking about the literature. Yeah, the Eric’s stuff is seminal it’s at the heart of this. To get expert feedback for deliberate practice, to really entrench the new skill acquisition and be able to show it on test day, part of that is you need experts sitting there beside you giving you feedback the entire time. Well, we don’t do that. That would be like months and months of us sitting on your shoulder. So my concern building this was how do we do that? So the idea is that we’re teaching you to be your own coach. So it’s like an expert emulator, like an old, like a video game emulator. So they can use the process and use the tools ’cause they can read the answer explanation. They know what’s right and what’s wrong. And they have this very rigid process. They can train themselves with the expert emulator to get constant feedback to reinforce what’s right versus what’s wrong. And that’s where the behavior change comes and trenches it as they move forward without us. And I’ve done this long enough–

And that’s the key. I really appreciate that too, because as I was writing my book and the methodology that I lay out in my book, that was a big concern for me. The students at my program here at Notre Dame, they have me to work with. They can come and see me. We can work through some of these issues, but the book was really designed and written to help students that don’t have a learning specialist like yourself available or an academic coach or anybody that can help them through this. And they can act as their own coach by learning how to do different things. So that is another piece. I’m starting to get into that with your unit three here. And I can see that’s a really huge.

Yeah, that’s where you take the exciting ideas and then you make them actionable and tangible and actually get these results. It’s one thing to say, you’re gonna change study method in the classroom years. It’s so much more multifactorial and you’re waging wars on multiple fronts against an enemy that’s variable and changing. With boards, you pretty much know what you’re dealing with. You know what they look like. You can match the strategies right up against the construct of the specific board exam and train for that. It’s a different thing with the board’s workshop. Now we had a few things we wanted to talk about beyond getting a little bit more into test taking stuff. So we had let’s see, one thing you said was you were able to narrow down to two, right?

Yeah.

And that ties in with the definition of the bad test taker. The way I identify a bad test taker is usually in the interview process. And I’m asking them, okay, you do a handful of questions. Now this is at a board’s prep level. You do a bunch of practice questions and you miss 10, 10 is a nice round number. So you do 20, 30, 40 questions, you miss 10. And then you read the answer explanation for the 10 and you’re trying to sort them and do one of two categories. So maybe each missed questions represented by like a poker chip on the table in front of us. You read the answer explanation. If you’re just gonna miss it just didn’t know it, couldn’t remember it, never saw it, had it encoded wrong. That goes over here on the left, on the knowledge stack. I just didn’t know enough, fair. The other side of that test taking, this is where I narrow down the two, not just narrowed down the two and missed it, but narrowed down to and realize I should have picked the right answer. I focused on one clue in the passage and didn’t look at the other clues. This is where I made a prediction. And that prediction rode me all the way to the wrong answer. Maybe I saw the wrong answer down there and shaped my reading to get to it.

It happened to me once on one of the questions. Yes.

For sure. These things happen all the time. See, and so then if it’s three, four, five, six, seven out of 10, I mean, obviously, once you’re over three or four, you’re a bad test taker. 40% of your misses are avoidable, unforced errors.

Right. Absolutely. The purpose of this isn’t to get into the methodology, but you have a particular set of approaches or strategies that you can use when you get to a point where you think you’ve got two possible–

Tie breaks.

The tie breaks. And the methods that you talk about helped me to in some cases break that tie and say, oh yeah, okay. This one’s right, this one’s wrong because of this clue that I missed, or I went back up to the passage and really retriangulated my clues, or looked more closely at the prompt to make sure that I was answering the right question.

The specific question being asked or it opened up a door to partial false instead of partial truth.

Yes, exactly. Again, my struggle with these types of questions again, is I’m not a physician, I had never went to medical school. But I was just floored by the fact that wow, just the methodology really helped me–

Structure.

Yeah the structure, right. The structure of the process really helped me to work through questions. And it was fun. That was the other thing. Again, I wasn’t taking it to get licensed or for a grade, but it was fun to do, it was like solving a puzzle.

Well, I tell people that re-engineering your test taking can be very stressful because it’s behavioral and we go against the grain of our behaviors, but it is ultimately for them, especially the bad, I mean the truly bad test takers, it’s invigorating. They might say fun, but they’re more likely gonna say it’s invigorating because their veil’s been pulled back. They can see the hidden structure. They can see where their behaviors are on and see where they’re off. They can never see the boundary lines. It’s like they were playing basketball and they’re a good basketball player, but everybody else sees the proper in-bounds and outta bounds lines. And they’re seeing like the in lines, like two feet narrower, shorter and the outta bounds, like three feet wider. So people are getting mad at them ’cause they’re dribbling outta bounds or slapping the ball outta their hands. When they think it’s inbounds and side bounds, it’s maddening. So by adding structure and unlocking their ability, it’s very gratifying. I guess what I was trying to say was like, not all tie breaks are test taking in nature. Like you said, sometimes you narrow down to two and your knowledge–

Yeah, absolutely. The case where I did that, I just didn’t know.

That’s an important, whereas some people narrow down to two and they’re always pushing away from the right answer. And that gets into some of the methodology. You identified a handful of things we were gonna touch base on, talk about, and we haven’t gotten there yet. So let’s talk a little bit about some of this. The first one was, and this is gonna open this up a little bit more than I usually go. I usually start talking about this at the medical boards level.

Okay.

But we’re gonna open this up a little bit and talk about the didactic test taking.

That’s really where I’m at. Yeah.

This is where you live. And I think it’s interesting thing to talk about. So talking about the challenge of writing and plugging into good, clear, fair test questions for the student. This is like in those first and second years when you’re in the classroom years, I think you wanna talk just about some of that stuff. And then I was gonna talk about my perspective on how we handle that, because of course you’re someone who’s writing exams for first years and second years.

And third year pharmacy students, yeah.

And third year pharmacists. And then you’re thinking about how can you help them? How can you help your faculty peers write better questions? What I say is these questions, they can be great all the way to borderline crimes against humanity when you’re in the classroom years. ‘Cause of course you’re watching these videos and it should also be noted, he’s texting me nonstop while he is watching these. Like, what about this idea? What about this idea? And I’m like, that’s great. That was great. I love it. But the thing he is like, one of the things you texted me was like, okay, this is cool for boards test takers, but you were asking me, could this then be shaped to help test takers hack into bad didactic classroom exams. I think that’s what you asked, right?

Yeah.

What was the motivation there? What were you thinking about there?

Yeah. Wow. First I’m gonna, what I’ll do is maybe pull the curtain aside a little bit and give everybody a peek again, behind the curtain, in terms of what goes on in faculty offices, across the country. I’ll apologize to my academic colleagues right up front. And as I’ve always said, everything I’m gonna talk about all the mistakes and horrors I’m gonna talk about, I have been guilty of them myself, okay? So I’m convicting myself of this right now. Writing good exam questions I have found is incredibly difficult. It is not an easy, easy thing to do at all. But it’s so critical because exams as I’ve told you. And I have some teaching fellows in a fellowship program that I work with and I tell them this all the time are that exams are artificial constructs. They are artificial things, tools that faculty create, okay. Or educators create in order to hopefully measure a student’s level of knowledge and skill, depending on what type of exam it is. And as faculty, we hope that the tool that we create to measure that will give us accurate data. With today’s exam, computer exam software, the software platform that we use at our school’s ExamSoft. And we get a whole ton of statistics on our exams and how reproducible are the results and how discriminatory are the questions and things like that. So we get a lot of data that I didn’t get when I started in my career many, many years ago. But what oftentimes happens is that again, faculty don’t usually get training in writing exam questions, okay? I know I did, so I spent years writing exam questions that when I look back on them today after having some development in this area, I just cringe. I’m like, oh my God, I can’t believe I did that to my students. And so it’s become a real passion of mine to really make sure that when I’m creating an exam, that my exam questions are linked to learning objectives that we cover for each one of our lectures and that they’re all linked and that the exam questions themselves are distributed across Bloom’s taxonomy. So we don’t have an exam where you have 50 questions and they’re all at high level application, like third order questions, but they’re a mix. One thing I was totally guilty of and your clients and your listeners can appreciate this is I used to get into what I refer to now as Ernest Hemingway mode. When I wrote an exam question, I would write these questions that were a paragraph long. And you get to the end and there’s the prompt in the question. And then the four or five answers and someone pointed it out to me at some point another colleague of mine. And I learned it in development sessions. I didn’t need the paragraph, all I needed was the prompt, and I was just indulging myself in my writing and it was making it very difficult for my students to navigate those questions, right?

Yes, absolutely.

Or questions that are double negatives.

Oh, yeah, terrible stuff.

And we do it just because we wanna try to make it a challenging, right?

Well, there’s probably some weird overcompensation, because the answers are so obvious to the test designer.

Yes.

And we’re so worried about making the question so ridiculously easy or so ridiculously obvious. That’s probably another factor that’s not spoken about.

Absolutely. I think you’re right. I didn’t even think about that, but you’re right. I think it’s like colleges do it.

Well, these questions are house of cards. Like if you make a valid question and if you get in there and you modify, or miss encode, like the wrong clue, you’ve now made two answers potentially right. Or the way you’ve written it, you allow room for wiggle room to have a secondary option be a viable candidate. It’s terrible stuff. You talk about–

Unfortunately for us the statistics will tell us when that happens. And then again, we can go back in and give partial credit or credit for two, we can adjust that on the back end but optimally, it’s always better to have a correct on the front end, right up front.

Oh yeah.

Right?

Yeah. You talk about the artificial construct of the exam quite. Like these are artificial constructs, what’s your take on how do students interpret these constructs? Do you think that the test takers appreciate the artificiality of these constructs or what do you think on that?

I think what we try to do is to make them as realistic and genuine as possible, especially again, I’m a scientist. And I teach in a health professions program. So it’s challenging for me to write science questions that are related clinically, right? But our clinical faculty members, they can write case vignettes. And we do have clinical case vignettes on many of our exams. And so they try to make it realistic. But again, if you’ve got a poorly written question or you’ve got excess detail, that’s just not necessary for the exam taker to navigate. Or if you use like slang terms, that’s another one, or extremely technical vocabulary terms that people may not be familiar with. It just throws people off. And then what you’re getting is the people miss the question. And I know this resonates really well with you. I find that people miss questions, not because they don’t know the material, but because of reading comprehension and their ability to navigate all this stuff. So I’ve worked really hard myself over the last five years or so to really tighten up my questions, especially if there are those binary types of questions where the answer is either it is just one answer and it’s just right or wrong. There’s no need to really do any convoluted thinking or it’s all about recalling facts and information.

Yeah. In those first order but here is how I talk to my students and my med students and my physicians about artificial constructs.

Yeah. Go ahead.

All right. So this is for the bad test taker. Let’s think like they’re clinically, they’re outside of the step one, level one they’re in the clinic experience. I just worked with a group of pediatricians and surgeons and we were talking about this. We’re doing like a peds question. I was trying to remember what the scenario was, it doesn’t really matter. And they end up, it’s most appropriate next step in management.

Yeah. Staircase.

Yeah. Staircase question, okay? And they end up choosing the thing you would do higher up the staircase. Not precisely next.

So if you have a medical treatment With multiple steps, right? You got step one, step two, step three, the questions asking if I’m understanding what you’re saying for the step one in the treatment, and they are jumping to step three, ’cause they recognize it as a answer.

That’s for sure. But here is why, they are trained to think clinically. These texts. These questions are artificial constructs. They are two dimensional constructs with the illusion of being three dimensional or maybe even four dimensional if you want to add time continuum.

Yeah. No, I think so.

Right, it is. Because what they’re doing is they’re trying to… Okay, they meet the patient, the flesh and blood patient, they’re collecting the history. They’re putting all these various streams and tributaries that are running from this history into the construct that is like in the real world the patient. And then their brain starts building out the continuum of what they’re going to do with that patient. And it’s a multiverse ’cause it’s like, if I get to this, then this, if I get to this and I find out this, so they’re thinking not just in a single linear progression moving forward, but with hypothetical branches branching off and they’re holding all that in their head.

Oh yeah, no, there was a case question that you did just that illustrates, I think that beautifully, and I don’t remember all the details, but it was a woman, it was one of these practice questions, a woman who had just had a mastectomy three days ago, right?

Yeah.

She’s come in, she’s hypotensive, her heart rate’s like 112. And she’s got the bandage where the surgery was and I made a mistake here. It asked what was, she just presents to you, what’s the next step.

Initial. Probably initial.

You’re talking about, right?

Yeah.

And the correct answer was to remove the dressing to inspect the wound. And I went right to start an IV give a bowls of fluid because the blood pressure was low and I’m sitting here thinking to myself probably what’s realistically happening in an ER, is that you’ve got somebody starting an IV while you are dressing the wound.

Yes. There’s two or three things happening at once.

Right. Exactly. And so that’s the perfect example of that clinical thinking and experience, right? I can imagine.

Oh yeah. The problem is for some of these bad test takers, now good test takers they’re like clearly, like this isn’t even worth talking about, the good test taker can manage this. Remember test taking is an act of reading. And so when we read, we deploy subconscious strategies, subconsciously, right? Subconscious strategies deployed to meet the needs of the textual construct. The construct that build of these test questions are unique. We need strategies to make the most out of these questions that we use nowhere else in life, not even other multiple choice questions, first order questions from undergrad or grad school or something like that. And if you’re deploying the wrong strategies, which are again subconscious, then that’s where these things happen. So the problem is, it is like a distortion of the prompt, the question being asked, but it’s a little more intertwined as well because it’s where reading and thinking are crashing into each other and they end not… Again, they’re dancing down the timeline and grabbing this thing that’s not precisely anchored to the fixed point. So they’re building out what looks like a time, imagine like a timeline of the 20th century. And then in 1984, it branches off into different timelines, like infinity war or mid game. It’s branching out and okay this happens this way. Yeah. Well, right. We have to think about which ones are on the same timeline, which branch off in a different, I have think about that, but this is the thing. So they’re thinking about that whole timeline. They’re building out with the possible multiple futures, but a test question is just asking for a single fixed point on that timeline. And if you can’t identify that single fixed point, then who knows what you’re gonna do and that’s something that we have to sort. And that’s very learnable. You can get people into shape on that.

I know but I can’t, I just can’t imagine how difficult that’s gotta be for a practicing physician. Like you said, when they’re looking at this question or think about these questions, you’re right that’s where my brain would go. What patients have I seen that looks like this. And then I’m imagining or remembering what’s going on versus approaching the question from a very disconnected standpoint, neutral.

It’s building the shield of neutrality. You can build all these things. And again, most physicians, most med students, most PharmDs, they just do this innately. So this is not a broad scale but broad spectrum solution. I understand people might get tripped up here and there. But there are degrees of severity here. There are some people that would listen to this and be like, oh yeah, that’s interesting. That would never happen to me. Some people might listen and to be like, oh, that sort of happens to me. But there are other people who are like, this guy is in my head, he’s speaking my reality. He’s speaking to my pain. He’s speaking to my agony. There are scales to this and degrees of it. But the good news is it’s totally learnable. I’ve met people where I’m like this is never gonna work, but all the stuff is eminently learnable, especially when it’s embedded in a structure. When it’s given context, when it’s given rules and feedback is built into it.

Thanks for tuning in to this episode of the STATMed podcast. Next week, Ryan and Dr. Culhane will continue their conversation about test taking on medical boards and in the classroom. If you like the show, please be sure to rate it on iTunes, Stitcher, Spotify, or wherever you listen to your podcasts. You can find more test taking and studying strategies specifically designed for med students and physicians over at our blog on STATMedlearning.com. Thanks for listening.

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