The knowledge base of medical students is evaluated by multiple choice examinations either produced by the Faculty, or by outside agencies such as the National Board of Medical Examiners. Knowledge base is also examined by oral examinations in some of the required clerkships. Interviewing skills, interpersonal skills, performance and interpretation of the physical examination, the utilization and interpretation of laboratory findings, diagnostic skills, and patient management skills are assessed at the bedside, during case presentations by students, and in one on one sessions with attending physicians or residents.
Multiple choice examinations are used by basic science and clinical clerkships to evaluate knowledge base. Basic science examinations are generated by the faculty that teach in each course. Clinical clerkships use discipline specific examinations prepared by the National Board of Medical Examiners. In addition, the School of Medicine requires passage of Step I of the USMLE for promotion to the third year, and passage of Step II before graduation from the School. Thus, good skills in answering multiple choice questions are useful throughout medical school. Our working hypothesis is that most students can increase their scores on multiple choice examination from 5 to 15% by practicing good test taking techniques regardless of who wrote the examination.
1. The single most frequent error students make in multiple choice examination is to misread, and therefore, misinterpret questions. Many students read the foils (possible answers) of the question before they have checked to insure that they understand the question. Often they find a possible answer to the misunderstood question, and, of course, the answer is incorrect. There is a simple process that will cut down the errors made by misreading the question.
First, cover the foils with your hand and then read the question. Ask "what is this question asking"? Rephrase the question in your own words until you understand the question. Then, without looking at the foils, ask yourself "what do I know about that"? Ask yourself a question that will get you thinking about the subject of the question and jot down what you can remember in the margin of your exam paper.
Secondly, review the foils carefully, marking out those that you know to be incorrect. In a well written question, there will usually be two choices left after mark out. Again, question yourself, "what do I know about this or that"? This interrogation will get you into the memory banks where the knowledge is stored.
As mentioned previously, this technique will work on National Board Exams, and is the technique used in the First Prep Program that is available to second year medical students preparing to take Step I of the USMLE.
2. Many medical students have a high error frequency on "negatively phrased" questions. These are "all are correct except" type questions. You are looking for the one "False" response. After making sure that you have read the question correctly and understand the question, simply write a big F along side the foils to remind you about the needed "False" answer.
3. Anxiety and fatigue cause students to miss question for which they know the answer. Both conditions show up as a rather specific pattern of errors which can be corrected once the reasons are known.
There are basically two types of error patterns caused by anxiety. Many students are very anxious when they begin an examination. Gradually, the student becomes more composed and the anxiety diminishes. Students with this type of anxiety will answer more questions incorrectly in the first one-third of the examination than in the middle or last one-third.
An error string is a cluster of three or more errors in a row usually caused when a student gets a surge of adrenalin. This second pattern of errors caused by anxiety occurs because students believe they made and error or became angry at the examination (psychological projection). Since a sudden surge of adrenaline is not conducive to mental concentration, it is likely that errors will be made in the questions that follow.
One way to correct the first pattern of errors is to carry out a 20-30 minute test-warmup session just prior to the examination. This is done by taking a few questions from an old examination without the foils. Find a quiet place and practice reading and rephrasing the questions. The idea is to get yourself thinking about the subject material and to begin to concentrate. Some students will wear earphones and play soothing music, perhaps something of Mozart while doing this. It works.
The second pattern of errors caused by a burst of adrenalin can be handled by letting the panic sensation subside before going ahead. Keep in mind that all questions have the same weight and that one question becomes heavier only if you allow the adrenalin surge to affect you to make more errors.
Fatigue patterns usually show up in the last one-third of an examination unless a student is so tired when he/she comes into the examination that they do not think clearly. This is the usual fate of all night crammers.
A sure cure for the fatigue pattern of errors is to get a good nights sleep before an examination, to eat a healthy diet with little if any caffeine intake, and , to exercise properly to release tension and manage stress. Cramming is a sure way to lose points due to fatigue. (See Stress Management).
4. Passing over questions that are difficult and/or changing answers both can contribute to a higher frequency of error than lack of knowledge base would cause. In the first case, leaving questions unanswered generates anxiety since students tend to keep thinking about going back to answer them and wondering if they can answer them. We have already seen what anxiety does to concentration. Students do not need the extra baggage caused by leaving questions unanswered and then having to come back to answer them. Changing answers is another common behavior in test takers. To see if changing answers is of benefit to you, go back through old exams and note where you changed answers. Tally the changes by noting those where right was changed to wrong, wrong was changed to right, and wrong was changed to wrong. If you have a consistent positive score, please continue to review and change. Most students gain little from changing answers and only take time away from working on other questions.
A positive test taking characteristic is to approach each question as a problem to be solved, process the question in the time allotted per question, give your best answer, move on to the next question and leave worry about the preceding question behind.
Oral Examinations are used by some required clerkships as a method of assessment of the students knowledge base and to assess the students response under the conditions of the oral examination. Some oral examinations are very informal and easy going, while others may ask the student to stand in front of a couple of attending physicians and perhaps the head resident . Each M.D. in the room will have an opportunity to address questions to you. Questions may be wide ranging, and, very frankly, may not be designed to assess any of the learning objectives of the clerkship. Questions may be asked about essential basic science knowledge (i.e. anatomy of the abdominal wall); normal physiological processes and how these may be affected by disease processes (i.e. normal process of wound healing vs contaminated or infected wounds); diagnosis, treatment and patient management issues for patients that you have seen or for disease processes for which you are responsible. There are some basic skills that you can use to do well on oral examinations.
1. The first skill is to learn to be an active third year medical student. Take responsibility for your own learning. To be an active learner on the clinics you will review your patient’s overnight progress before work rounds (see Clinical Skills), and will be an active participant in work rounds by asking questions of the attending or resident about things that you do not understand. During the day, learn from your patients, and during off times, read, read, read. Each clerkship will assign a textbook that should be read from cover to cover. As you read, utilize a reinforcement-advance organizer approach (see Study Skills) to build your knowledge base in a progressive manner. Be especially well-prepared for the diseases that you learned about by direct patient care. You can periodically evaluate your knowledge base by picking up a Step II review book that contains multiple choice questions over the subject material your are learning.
2. The second skill is to learn how to give excellent presentations (see Clinical Skills). Learning to present your patients to the teaching team will develop the confidence needed to respond to questions on your feet. Also, pick a study buddy or two from your teaching team and practice asking each other a series of questions and then critiquing each others performance.
3. The third skill is to examine the question just as if it were the stem of a multiple choice question. Repeat the examiner’s question in your own words and ask if your understanding is correct. Then begin to process the question by asking yourself where you would have studied that information. Organize in your mind, use the blackboard if you have too, and if you get stuck, admit that you do not know.
Keep in mind that you are being evaluated almost every minute you are on the wards by your teaching team, the other health care professionals with whom you work, and by your patients. Not all of the good evaluations reach the Dean’s Office. However, bad stuff frequently reaches the Dean’s Office (see Clinical Skills). This is especially true if your behavior on the wards in disrespectful toward other health professionals. Some students say that other health professionals were disrespectful toward them first. You can not control how they are, you can only control how you respond or act toward others.
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