Every U.S. emergency medicine resident participates in an annual ritual on the last day of February each year: the In-Training Examination (ITE) given by the American Board of Emergency Medicine (ABEM). The residents sit in the same area for up to four and a half hours, and answer roughly 250 questions of variable quality. (How do they consistently find the worst x-rays ever taken to include in this exam?) The test does provide, however, an estimate of each resident's ability to pass the written component of the ABEM certification examination after graduation.
There are likely as many strategies for doing well on the exam as there are questions, and they are passed down like family recipes. They include nitpicky items to remember for the few hours you take the exam that are quickly dumped from your brain's RAM while guzzling beer with your classmates and complaining about the crappy x-rays. Every class has someone who finishes in 90 minutes and tosses the test at the proctor as he skips out of the room. These showoffs routinely score in the 90th percentile and attract everyone's anonymous scorn. There are also the residents who milk every second of the time while furiously changing their minds again and again on the coin-flip questions.
Most residents do pretty well. After all, the gene pool for getting into an EM residency is pretty stiff, and good scores are often the first filter used to cull the herd. Nonetheless, some residents still struggle on the ITE. Why?
Poor performance on an exam can be distilled to three explanations: the person taking the test is not smart enough, the person has a learning disability, or the person did not study. You do not have to be Einstein to figure out which of these is behind a poor score on the ITE. When I ask residents why they did poorly on the test, they always say they didn't study.
In front of me are intelligent, highly-motivated people who have proven to be excellent test-takers. They know the content for the exam far in advance, and they get all kinds of advice from their predecessors about how to excel. The score is not on a curve, so doing well would seem relatively straightforward. There is even a cottage industry of books, videos, practice questions, and websites set up to spoon-feed residents the information they need.
Bombing the ITE
Yet I usually have a resident bomb each year. We're talking below-the-10th-percentile bomb. I can't even predict which resident will do poorly. Sometimes you think the guy with three kids and a newborn at home will be too busy playing daddy, but he does fine. Then you have a resident with no significant other, no kids, and not even a dog, and he blows it. Don't they realize that doing well on these tests is necessary to get the job that will pay them very, very well over the course of their career? Isn't this why they worked so hard to get into residency?
The bottom line is that there are a lot of reasons they don't study, but there is one good way to fix it: structure. The millennial generation has access to more information than anyone in human history, but they are also less organized to use it constructively. I suspect the abundance of available entertainment on a smartphone impairs a person's ability to focus on pragmatic issues. When I ask why they are not studying, most just shrug and say they get distracted at home too easily.
I have a cure. PGY-1 and PGY-2 residents who do not score in least at the 50th percentile for their class compared with the rest of the nation are assigned to admin shifts for the six months leading up to the next ITE. They come into our department office, check in with the residency coordinator, turn off their phones, and sit in a quiet room for four hours to study. Typically, they get two of these shifts a month. No other instructions. No other tricks. No study lists. Just sit in a quiet room.
Before you groan at this Draconian policy, consider this: Our residents who scored below the 10th percentile over the past six years were required to study in our department office; all except one scored above the 95th percentile the next time they took the exam. This year we had five residents who did not score in the 50th percentile the previous year, and their average raw score went up 14 points after studying in our office.
The solution might not be a breakthrough psychological strategy, but rather something as simple as shutting out the noise. Our collective existence has become a ceaseless cacophony of sound, data, and imagery. We are addicted to it, and an infinite supply of websites can occupy every second of our days. Our lifestyles have become a struggle to find quiet places where we can reflect and focus on nonurgent but important tasks. Just 40 years ago, humans spent a lot of their time with little or nothing to do. Many of us (including me) thought it was boring and unproductive. The great irony is that now we have to search for silence to help us accomplish our most important objectives.
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